Denali Dental Appointment

Applicant Information

First Name

Middle Initial

Last Name

Home Address

City

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.

Were you referred by another agent?

Please enter the name of the agent.

National Producer Number

Don't know your NPN? Click here to search.

Agency Information

Business Name

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 State

Business Zip

Business Website

Assignment of Commission

Commissions are to be paid/assigned to:

Agent/Producer

Agency/Company

Commission statements are to be mailed to:

Agent/Producer

Agency/Company

Other

Assignee Information

Name of Person Responsible

Email Address

Please only enter a single email address.

Tax Class

Tax ID #

Mailing Address (if different)

City

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

City

State

Zip

Account Type

Checking

Savings

Routing Number

Account Number

Errors & Omissions Insurance

Name of Carrier

Policy Number

Expiration Date

Name of Insured

Policy Limits

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 complete your application. If you are unable to upload copies of these, you may also email it to agentsupport@directbenefits.com or fax it to (651) 649-3502.

MWG will appoint agents in each state(s), as they sell their first case in that state, and its confirmed that their license is an active and valid license.