Date
Sunday, May 20, 2012
Agent Enrollment
First Name
Last Name
Date of Birth
 E-Mail
  E-Mail address will be your User Name.
 Confirm E-Mail  
  All important NYDN communication will be via E-Mail.
Password  
   Please create a password of 4-8 characters, using at least one number. This is not case-sensitive. Password will only be used when editing personal or financial information.
Entity, only if you operate under a business name
Your Federal I.D. number (or) Social Security Number
Your Address
Suite/Apt 
City     
State     
Click to drop down
Zip     
Phone Phone
- -   Digits only: 123 456 7890
Fax  
- -   Digits only: 123 456 7890
NYDN Uses E.F.T (Electronic Funds Transfer) As Only Option For Agent Compensation
Bank Account Number For E.F.T Payments
Bank Routing Number
Bank Name
Name(s) That Appears on Check
Are you a licensed Life / Health Agent ?
Yes No
Are you a licensed Prop / Casualty Agent ?
Yes No
Are you a licensed Sec/ Equities Broker ?
Yes No
Have you ever been convicted of a felony or misdemeanor other than a routine traffic violation?
Click to drop down Yes Click to bring up No
Have your ever had an insurance or equities license revoked or suspended or has any professional licensing authority taken disciplinary action against you
Click to drop down Yes Click to bring up No
Clicking '"Submit" does not automatically enroll you as an NYDN Agent. After you submit this form, we will review your information and contact you.
Please wait for us to contact you with Agent Agreement information for you to sign and return to us. Once you have returned the signed Agent Agreement, your status as Agent will become active. If you have any question, please contact us.
All NYDN Member Enrollment And Payment Is Done On Line.
No Payments Are To Be Collected By Agent.
Read NYDN Agent Agreement.
NYDN Is Not an Insurance Company. This Plan Should NEVER Be Represented As Insurance.
New York Dental Network, LLC is a Reduced Rate Dental Plan.