California Dental Network, Agent & Broker Appointment
Step 1: Obtain a copy of your CA Insurance License.
- Click here to visit the CDI License Page and print a copy.
Step 2: Complete the California Dental Network, Agent Agreement
- Click here to complete the California Dental Network, Agent Agreement (pdf form)
- Print and SIGN the completed Agent Agreement
Step 3: IRS form W-9
- Click here to complete an IRS Form W-9 (pdf form).
- Please ensure that the Legal Name filed with the IRS and that is tied to the TIN is correctly entered on Line 1. Also, if you are a Covered CA certified agent and intend to sell the CDN Covered CA individual and group plans, the Legal Name MUST MATCH the TIN that was registered with Covered CA.
- Print and SIGN the completed W-9 form.
Step 4: Complete the California Dental Network Direct Deposit Authorization
- Click here to complete the CDN Direct Deposit Authorization Form (pdf form)
- Print and SIGN the completed Direct Deposit Authorization Form
Once you have a copy of your license, and you have completed and signed the above documents, please submit them to CDN via:
- Mail: California Dental Network, Inc.
Attn: Marketing Administration
P.O. Box 2428
Laguna Hills, CA 92654
- Fax: 949-407-7185
- Email: email@example.com. Due to the private nature of some of the information included, we recommend sending these documents password protected.