Denali Dental Appointment

Applicant Information

First Name

Middle Initial

Last Name

Home Address

City

County

State

Zip

Social Security Number

Drivers License Number

Date of Birth

Gender

Male

Female

Home Phone Number

Cell Phone Number

Home Fax Number

Email Address

Please only enter a single email address.

Working with GA?

Please enter the General Agency Name.

Agency Information

Business Phone Number

Business Fax Number

Email Address

Please only enter a single email address.

Tax ID #

Business Tax Class

Business Address

Business City

Business County

Business State

Business Zip

W-9 Information

Instructions are available here

1. Name (as shown on your income tax return)

2. Business name/disregarded entity name, if different from above

3. Select the federal tax classification of the person whose name is entered for item 1 above.

For "Limited Liability Company", enter the tax classification

For "Other", enter the classification here

4. Exemptions (codes apply only to certain entities, not individuals)

Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

5. Address (number, street, and apt. or suite no.)

6. City, state, and ZIP code

7. List account number(s) here (optional)

Taxpayer Identification Number

Social Security Number

Employer Identification Number

Assignment of Commission

Commissions are to be paid/assigned to:

Agent/Producer

Agency/Company

Assignee Information

Agent Name or Agency Name Receiving Commissions

Phone Number

Tax ID #

Tax Class

Status

Mailing Address (if different)

City

County

State

Zip

Bank Information (Direct Deposit)

NOTE: Checks need to accrue to a total of $25 and direct deposit will need to accrue to a total of $5 before the commissions are issued. Your check will be deposited the second working day of each month and your statement will be sent via U.S. mail the second working day of each month.

Name on account

Financial Institution

Phone Number

Address

City

County

State

Zip

Account Type

Checking

Savings

Routing Number

Account Number

Agent/Agency License

Please upload a copy of your agent/agency license

Attach E&O

NOTE: Files must be smaller than 1MB. A copy of your agent licensing (and agency if applicable) and a copy of your E&O is REQUIRED to complete your application. If you are unable to upload copies of these, you may also email it to concierge@directbenefits.com or fax it to (651) 649-3502.

Additional Information

Select the states in which you would like to be appointed.

State 1 (required):

State 2:

State 3:

1. Have you pled guilty or nolo contendere to or been found guilty of a felony or a crime involving moral turpitude since becoming licensed for health insurance?

Yes

Please explain this:

2. Have you, or has any corporation, partnership, association, or firm in which you were a director, officer, shareholder or partner, ever been the subject of any administrative, or legal action filed by a state insurance department; or any action filed on behalf of any state, or by the federal government based on alleged violation of state or federal insurance laws?

Yes

Please explain this:

3. Has your insurance license ever been suspended, revoked, or terminated, or have you ever been the subject of any administrative or legal action filed by a state insurance department?

Yes

Please explain this:

4. Do you maintain errors and omissions and general liability insurance coverage?

Yes

Please explain this:

5. Are there any outstanding or pending judgments or liens (including state or federal tax liens) against you?

Yes

Please explain this:

6. Have you ever been discharged or permitted to resign from your employment because you were accused of:

a. violating investment-related or insurance-related statutes, regulations, rules, or industry standards of conduct?

Yes

Please explain this:

b. fraud or the wrongful taking of property?

Yes

Please explain this:

c. violating company rules?

Yes

Please explain this:

7. Do you have any outstanding unpaid indebtedness to an insurance company or general agent?

Yes

Please explain this:

8. Within the past 10 years, have you ever had a complaint filed against you that resulted in a fine, penalty, cease or desist order, censure or consent order?

Yes

Please explain this:

9. Within the past 5 years, have you ever initiated bankruptcy proceedings or been declared bankrupt?

Yes

Please explain this: