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
A
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
(Required)
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
City
State ZIP Code
Home Phone # (XXX) XXX-XXXX Date of Birth (MM/DD/YYYY)
Male Female
Brok
er
Social Security #
B
Personal Information
Business Address
City
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)
40589
