California Dental Network, Agent & Broker Appointment

Step 1: Obtain a copy of your CA Insurance License.  

  1. Click here to visit the CDI License Page and print a copy.

Step 2: Complete the California Dental Network, Agent Agreement 

  1. Click here to complete the California Dental Network, Agent Agreement (pdf form)
  2. Print and SIGN the completed Agent Agreement

Step 3: IRS form W-9

  1. Click here to complete an IRS Form W-9 (pdf form).
  2. 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.
  3. Print and SIGN the completed W-9 form.

Step 4: Complete the California Dental Network Direct Deposit Authorization

  1. Click here to complete the CDN Direct Deposit Authorization Form (pdf form)
  2. 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:

  1. Mail: California Dental Network, Inc.
    Attn: Marketing Administration
    P.O. Box 2428
    Laguna Hills, CA 92654
  2. Fax: 949-407-7185
  3. Email: ssampsel@caldental.net.  Due to the private nature of some of the information included, we recommend sending these documents password protected.