Careington New Broker Enrollment Form

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Careington is the premier marketer of dental, medical, health and lifestyle discount plans, as well as insurance plans through its affiliate Core Five Solutions, that help members save money on health care and other services.

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Contact Information

* = required field

First Name : * !

Middle Initial

Last Name: *

Company: *

Address 1 : *

Address 2 :

City *

State * !

Zip Code: *

Phone Number: *

Fax Number:

E-mail: *

Confirm E-mail: *

Web site:

(ex. http://www.0000.com)

Your broker website

You can add your company logo and personalize your Careington website.

Upload your logo
(Logo size should not exceed more than 370x90 pixels and formats of .jpg, .gif and .png)

Phone number: *

- -

Hours of Operation

Monday - Friday:

Select Time Zone:

Life/Health Insurance Information

State	License Number	Effective Date
	!	! !

You must have an active insurance license to be enrolled as a new agent.

W-9 Information

Social Security Number:

(ex. 000000000)

Employer Identification / Tax Payer Identification Number:

Is this a registered corporation? YES NO

W-9 Information
Under penalties of perjury, I certify that:
1. The number shown on this electronic form is my correct Taxpayer Identification Number
(or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because:
(a) I am exempt from backup withholding, or
(b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to
backup withholding as a result of a failure to report all interest or dividends, or
(c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien).

I agree that information above is correct

Authorization Agreement of Monthly Direct Deposit

Financial Institution: * ! !		Checking Account Saving Account
Routing Number * ! !	Account Number: * ! !

Electronic signature:
First Name: * ! !	Last Name: * ! !

I certify that I have read and will abide by Careington's Marketing Partner Guidelines. *

I agree that the information above is correct and accept the terms and Conditions of the Seller Agreement. *

Careington broker benefits

Flexible commission plans
Ability to sell to individuals and groups of any size
A Member Services department that handles customer issues
Availability of online applications so you can sell products via the Internet
Immediate appointment upon receipt of Producer Agreement