New agency (brokerage) application

Agency business name*

DBA name (if applicable)

Tax ID number*

Address*

State*

City*

Zip code*

Agency phone number*

Agency fax number

Head of agency last name*

Head of Agency first name*

Title*

Email address*

Other Agency contact name (if applicable)

Title

Email address

States/health plans (check all that apply)*

Wisconsin - Dean Health Plan

Wisconsin - Prevea360 (East)

Wisconsin - Prevea360 (West)

Email address to send monthly commission statements*

Licensed agent last name*

Licensed agent first name

Licensed agent NPN*

Does the agency have a current business entity license in the states you selected?*

Yes No

If yes, National Producer Number (business entity)

Errors & Omissions Liability Insurance for agency and agents, with coverage of $1,000,000 per occurrence*

Business entity policy covers agency and affiliated agents agents are required to provide proof of individual E&O coverage

Primary business market (check all that apply)*

Large group

Small group

Self-funded/Level-funded

Includes ASO (self-funded or level-funded)

Individual

Medicare

IPlanRx (WI)**

Have you previously had or applied for a contract with any of our health plans*

Yes No

If yes, please explain

Special considerations

Statement of intent*

New agency (brokerage)