Qualified Agent Form

 

Agent's First Name  
Agent's Last Name    
Oklahoma License Number    
Agency Name      
Address      
City      
State      
Zip Code      
County    
E-Mail      
Telephone Number    
Fax Number    

Agency/Agent
Website Address

   
       

4 Hour CE Course

Location

Date Of
CE Course

 

1.

4 Hour CE Test

Location

Date Taken

Score %

1.

2.

Employer Groups

Submit first 3 Employer Groups through an Outreach Coordinator First and Last Name of Outreach Coordinator Contact Method

1.

  
 
 

2.

  
 
 

3.

  
 
 

ESI Successfully signed up 5 IO Employer Groups FEIN E# (E0000xxxx)

1.

2.

3.

4.

5.

Contract Must have signed legal agreement on file Date submitted E-Mail/Fax

1.

    E-Mail Fax
Comments    
   
 

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