Applicant Information

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Agency Information

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Preferred Mailing Address
Assignment of Commission
Assignee Information
Bank Information (Direct Deposit)

NOTE: Both live checks and direct deposit amounts must accrue to a total of $25, before commissions are issued. Monthly commission statements will be mailed to agents along with live checks; commission statements are not issued electronically. Brokers who elect EFT/Direct Deposit, will be able to access commission statements via the agent portal.

Additional Information

NOTE: Licensing and Errors & Omissions Insurance is required to complete your application. If you are unable to upload a copy of your licensing and the summary page of your E&O there are a couple options: This can either be emailed to Carrissa@DirectBenefits.com or by fax at (651) 649-3502.