Broker Licensing Form
To ensure proper compensation distribution, please:
1. Complete all pages of this form. Sign and date where indicated.
2. Attach a copy of your Individual Insurance License, signed Agent Agreement, signed Broker Privacy Agreement, and completed W-9 form
3. Remit with your first case submission to: CHOICE Administrators
, 721 South Parker, Suite 200, Orange, CA 92868
Professional Information
Please print using black or blue ink
Important! Entire form must be completed to release commissions
Broker Last Name
Broker First Name M.I.
Broker License # Expiration Date (MM/DD/YYYY) State of LicenseLicense Type
Make commission checks payable to
Corporation Partnership LLC Sole Proprietorship Individual
If Corporation, Partnership or LLC, please provide
Company's Federal Tax ID #
If Sole Proprietorship or Individual, please provide
Social Security #
Company Name (if applicable)
E-mail Address
(1 of 2) CA 0100 11/2015
Please complete both sides of this form before signing
Residence Address
State ZIP Code
Home Phone # (XXX) XXX-XXXX Date of Birth (MM/DD/YYYY)
Male Female
Social Security #
Personal Information
Business Address
Business Phone # (XXX) XXX-XXXX Business Fax # (XXX) XXX-XXXX
State ZIP Code
Check if residence
Mailing Address (if different from above)
City ZIP CodeState
Company Structure or Individual Structure (Check only one)
Select One
(2 of 2) CA 0100 11/2015
Broker Licensing Form
The insurance department requires companies to investigate the competence, character and financial background of agents.
Please provide the information below:
(If the answer to any of the questions above is "yes," please provide details on a separate sheet.)
Yes No
Has your application for a license to sell insurance, real estate or securities ever been denied?
Have you ever had a license revoked or suspended, (or voluntarily consented to the
cancellation of such), involving the right to sell insurance securities, real estate or similar?
Yes No
Have you ever been convicted of any crime, whether a felony or a misdemeanor, involving
fraud, dishonesty, misrepresentation, mishandling of money (such as larceny, embezzlement,
conversion, etc.)?
Yes No
Does any insurer or general agent claim any indebtedness in default by you or your agency
under any contract or otherwise?
Yes No
re there any outstanding judgments against you?
Yes No
Have you ever filed bankruptcy or been involved in any insolvency proceedings?
Yes No
Print Name Date (MM/DD/YYYY)
He/she is currently authorized to sell life, A&H, and disability insurance products, and that he/she is in good standing with the
insurance regulators in the state(s) where licensed.
The answers and information provided in this form are true and correct.
The undersigned, by his/her signature below hereby agrees and certifies that:
Broker Signature
Please remit all completed documents to:
CHOICE Administrators
721 South Parker, Suite 200
Orange, CA 92868
E-mail to:
FAX (714) 972-7368
Staff Use Only
Broker #
Agent #
Supplemental Broker Information
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