o Broker Agreement – Signature page o W-9 Form o Individual and SHOP Marketplace Certificate of Completion (copy) o Wisconsin Health Insurance License (copy) o E&O Certificate of Liability Insurance (copy)General Agent/Agency Appointment • May 16th, 2016 • Wisconsin
AGENCY/SOLE PROPRIETOR INFORMATION APPLICATION FOR: Agency with Commissions Paid to the Tax Identification Number. Agent/Sole Proprietor with Commissions Paid to Social Security Number. Last First Middle Agency Name Applicant Email Address (required) Social Security Number Work Address Work Telephone Number FAX Number Other Telephone Number P.O. Box City State ZIP Code
