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New Appointment Form

The carrier provides DenTen with this form. Admin fills in the form with DenTen’s information and submits it to the carrier.

Note: The carrier may call this form an appointment questionnaire or appointment application.

To fill out a New Appointment Form:

  1. Open the email from the carrier with the new appointment information.
  2. Open the attachment with the new appointment form.
    The attachment opens in Adobe Acrobat.
  3. Save the document on your desktop.
  4.  Upload the file to DocuSign.
    This converts an unfillable document into a fillable one and enables signature authentication.
    Note: For more information, please refer to the DocuSign section.
  5. Fill out sections according to the table below:

Section Name

Information

Agency Name

Agency Address

Tax ID/FEIN

Business Phone

E&O Carrier

Cluster Group

DenTen License Number

Michael Esposito Broker License Number

Michael Esposito Agent License Number

Michael Esposito Life License Number

DenTen National Producer Number

Michael Esposito National Producer Number

 

 

 

DenTen Insurance Services, LLC

96 Haviland Road Highland, NY 12528

87-232-6266

917-885-2300

Rockwood Programs, INC

SIAA-SAN Group

BR-168-2973 Expires June 30, 2023

BR-144-8430

PC-144-8430

LA-144-8430

20043002

18223204

 

 

6.Save the completed Appointment Form.
7. Email the completed Appointment Form to Michael for approval and certification.
Note: The Appointment Form must be approved and certified before it is emailed to the carrier.