Nevada broker application
Thank you for your interest in selling our dental plans. Getting started is easy:
- Download the forms provided below and follow the instructions to complete each one.
- Submit your completed Nevada forms by email, fax, or mail.
Download required forms and instructions
Individual producer information: This section should be filled out by the individual producer (agent) that is applying for the appointment.
Organizational producer information (agency): This section must be completed if the individual producer (agent) is working through an agency.
On the third page, the individual producer (agent) must sign and print their name. Also, if there is an organizational producer, an officer of that organization must also sign (on behalf of the organization) and give their title. Both signatures must be dated by the person signing.
Assignor: This is the information for the individual producer (agent) listed in the individual producer information section on the Liberty Dental Plan of Nevada producer application.
Assignee: If the individual producer (agent) wants the commission payable to a separate party (usually the agency they are working through), they must complete this document. If the commission is to be paid to the individual producer, this document should not be submitted.
This document must be signed and dated.
This document must be completed by the entity receiving the commission. If the individual producer is the one receiving the commission, then their information should be placed on this document. If there is an assignee receiving the commission, then the assignee is to complete this document.
The information on page 8 should be that of the individual producer if they are receiving the commission. If the commission has been assigned to the assignee, then the assignee's information should be placed on this page.
The signature block on page 9 must be completed by the individual producer if they are receiving the commission. If the commission has been assigned to an assignee, then an officer of the assignee should complete the signature block. All four lines must be completed by the individual producer or an officer of the assignee as applicable.
Please include a copy of the Nevada insurance license. If there is an individual producer and an assignee as described above, we need a copy of the license for both as they both must be appointed by Liberty with the state of Nevada.
This is a federal form that must be completed correctly.
The address for the entity that receives commission should be used on this form.
In Part I, either the social security number box or the employer identification number box should be completed (not both). Use the number for the entity that receives the commission. It should be the same number used on their income tax form.
The entity receiving the commission must complete this document. The name on the first page (“Business Associate”) must be the legal name of the entity receiving the commission. The name must be the same as on the W-9.
The information requested at the top of page 7 (“If to a Business Associate”) must be include the legal name of the entity receiving the commission.
The signature box of the “Business Associate” must be completed by an officer of the entity receiving commission.
The printed name and title of the entity must be completed by the entity.
The entity receiving the commission must be the one to complete this document. The name on the first page (“Contractor”) must be the legal name of the entity receiving the commission. The name must be the same as on the W-9.
The signature box of the “Contractor” on page 5 must be completed by an officer of the entity receiving the commission. It must be completed in full to include the signature, printed name, title, and date.
Please include a copy of your Errors & Omissions (E&O) insurance declaration page. You can download this from your E&O insurance carrier’s online portal or request it from them directly.
Submit your application
Once we receive and approve all of the completed documents, you will receive an email notification that you are contracted with Liberty Dental Plan. Included will be executed copies of your Agent Agreement and your assigned Broker/Agent number. We are unable to pay any commissions until all of these documents have been completed, received and approved.
If you have any questions regarding this process, please contact Client Services at clientservices@libertydentalplan.com.
Liberty Dental Plan (“Liberty”) requires its Agents/Brokers who may, in the course of providing services for Liberty, have access to members’ Protected Health Information (PHI) to execute a Business Associate Agreement (BAA) and any updates thereto. The Business Associate Agreement sets forth all applicable privacy and security requirements under the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”) and Health Information for Economic and Clinical Health Act (“HITECH Act”). In addition, Liberty requires its Agents/Brokers who may have access to its (or its clients’) confidential information to execute a Nondisclosure Agreement (NDA) and any updates thereto.
We look forward to working with you to provide quality dental benefits to your clients!
Send a scanned copy of the completed attestation and survey to:
Fax
Send a printed copy of the completed attestation and survey to:
949-270-0114
Postal mail
Send a printed copy of the completed attestation and survey to: