Applicant InformationFirst Name* Middle Name Last Name* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number* Drivers License Number Date of Birth* MM slash DD slash YYYY Gender* Male Female Home Phone NumberCell Phone NumberHome Fax NumberEmail* 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 InformationBusiness Name Business Phone NumberBusiness Fax NumberEmail Please only enter a single email address.Tax ID # Business Tax ClassPlease Choose....Individual/sole Proprietor or single-member LLCC CorporationS CorporationPartnershipLimitedOtherAddress Business Address Business City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Business State Business Zip Business Website Assignment of CommissionCommissions are to be paid/assigned to:* Agent/Producer Agency/Company Commission statements are to be mailed to:* Agent/Producer Agency/Company Assignee InformationName of Person Responsible* Email Address* Please only enter a single email address.Tax Class*Please Choose....Individual/sole Proprietor or single-member LLCC CorporationS CorporationPartnershipLimitedOtherTax ID # Mailing Address (if different) Street Address City Please ChooseAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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* Address City Please Choose...AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Account Type* Checking Savings Routing Number* Account Number* Errors & Omissions InsuranceName of Carrier Policy Name Expiration Date* MM slash DD slash YYYY Name of Insured Policy Limits Agent/Agency LicensePlease upload a copy of your agent/agency licenseMax. file size: 1 MB.Attach E&OMax. file size: 1 MB. 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.QuestionaireWhere do you prefer to receive mail correspondence?* Business Home Please indicate your mail preference.
