BROKER APPOINTMENT FORM

(Please Print or Type)

APPLICANT INFORMATION

APPLICATION FOR: 1. As an Agency 2. As a Broker at an Agency 3. As an Independent Broker

Last Name First Middle Name Prefix Preferred Suffixes SSN/EIN (*required for appointment)

Agency Name Applicant Email Address Preferred Method of Contact

 Work Phone  Email
 Other Phone  US Mail
Work Address Work Phone Number FAX Number

P.O. Box City State ZIP Code

“Commission Payable to” Name

“Pay To” Address  Same as Above P.O. Box City State ZIP Code

Do you wish to receive payments from Bank Name Routing Number Account Number
SeeChange Health Via EFT?
Yes No
Bank Address P.O. Box City State ZIP Code Telephone

LICENSE INFORMATION
License Type State of Issue License Number Issue Date Expiration Date

Exact name on license You must include a copy of your current license with this Application. If
your license will expire within 30 days of the submission date, please
contact us for advice before submitting your Application.

ERRORS AND OMISSIONS INSURANCE

Name of Carrier (Attach copy of Certificate) Specific and Aggregate Amounts Expiration date Applicant or Agency
(Min. $1 Million each) must be noted on
the Certificate.

ATTESTATION
The Application information contained herein is true to the best of my knowledge. Date

Applicant signature

SEECHANGE ADMINISTRATIVE USE ONLY

Application Received By Date of receipt License Signature
E&O coverage
Broker contract
Appointment Date Kaplan approval? SeeChange ID Code
Yes  Appointment as  Broker  Broker Agent  Independent Broker
No 

Contact SeeChange Health

P.O. Box 711 - Fresno, CA 93712 • Ph. 888-237-6650 • Fax 888-691-3971
Email: Sales@SeeChangeHealth.com

AM 20110217 SeeChange Health Insurance Company, Inc.