Applicant Information

Please enter the General Agency Name.

Agency Information

Please only enter a single email address.

Bank Information (Direct Deposit)
Additional Information

Select the states in which you would like to be appointed. Please provide your license numbers for each respective state and attach a copy of the license.

Please also attach a copy of the deck page of your E & O coverage.

NOTE: A copy of your agent licensing (and agency if applicable) and E&O coverage is REQUIRED complete your application. If you are unable to upload copies of these, you may also email it to Carrissa@DirectBenefits.com or fax it to (651) 649-3502.

Questionaire

For the following questions, "you" refers to the individual or entity seeking to be appointed with Combined Insurance Company of America.