2480 Natomas Park Suite 150
Sacramento, CA 95833
Phone: 855-325-5200
sutterhealthplus.org
AGENT/AGENCY APPLICATION
SUTTER HEALTH PLUS
Please submit the following with this application:  Signed and Dated Agent Agreement
 W9 Form
 Proof of E&O Insurance Coverage
 Legible copy of the Agent’s current California Life & Health License
 Agent’s current FWA (Fraud, Waste, & Abuse) Training
 Verification of HIPAA Training
Section 1: Applicant Information
Applicant Type:
 Agency with Commissions Paid to the Agency
 Agent with Commissions Paid to the Agency
 Independent Agent or Sub-Agent with Commissions Paid to Themselves.
Last Name:
First Name:
MI:
Agency Name:
Work Address:
City:
Work Phone:
State:
ZIP Code:
Applicant Email Address:
Other Phone:
Section 2: License Information
License Type:
Issue Date:
State of Issue:
Expiration Date:
License #:
Name on License:
Section 3: Errors and Omissions Insurance
Name of Carrier:
Expiration Date:
Specific Amount (minimum $1 million):
Aggregate Amount (minimum $1 million):
Section 4: Commissions
Please choose and complete one of the below:
 Commissions Payable To Agency
Agency Name:
Agency Tax ID:
Agency License #:
Social Security #:
Individual License #:
 Commissions Payable to Individual Agent
Individual Name:
Pay To Street Address:
[Agent Application 06-19-13 v.3]
City:
State:
ZIP Code:
SHP/061713/AGENTAPP