Common Contracts
3 similar Broker Agreement contracts
BROKER AGREEMENTBroker Agreement • August 29th, 2016 • Wisconsin
THIS BROKER AGREEMENT (the “Agreement”) is made by and between Common Ground Healthcare Cooperative (“CGHC”), and the Broker (Broker”) set forth on the signature page of this Agreement. This Agreement is effective as of the date it is signed by both parties, as noted on the signature page hereto (“Effective Date”), and replaces and supersedes any prior agreement between the parties regarding the solicitation and sale of CGHC insurance products and any compensation payable with respect thereto.
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)Broker Agreement • 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
AGENT APPOINTMENT CHECKLISTBroker Agreement • September 9th, 2014 • Wisconsin
AGENT INFORMATION Last First Middle General Agent/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
