Sun Health & Dental — Producer Enrollment

Information

Agreement

Banking

W-9

Producer information

First name *

Last name *

Business name Optional — leave blank if you file as an individual

Email address *

Mobile phone * 10-digit US phone number

Home phone

Street address *

City *

State

Zip code *

Office phone

Preferred language * This is the language for your materials. It is separate from the EN / ES page toggle.

License & agency

I'm not a licensed insurance agent

License state *

License type *

License number *

NPN * Required for licensed agents

Are you enrolled with an Agency? *

Agency name *

Producer Agreement (SHDP-2026-10) — read carefully

Fields below are filled from your application. One signature is placed on the Producer Agreement and on the Commission Schedule Addendum.

Signature date —

Effective date Pending SHD countersignature

Loading full Producer Agreement…

I confirm that the information I provided is correct, and I have read and agree to the Producer Agreement. I have read and agree to the Commission Schedule Addendum.

Signature *

Sign once. This signature is applied to the agreement and the addendum.

Bank information — ACH direct deposit

Commissions are paid every Sunday via ACH for the prior week's earned sales.

Account holder name *

Account type *

ABA / Routing number *

9-digit number at the bottom-left of a check. We'll look up your bank automatically.

Bank name * Auto-filled when you enter a valid routing number. You can edit if needed.

Bank address *

Account number *

Confirm account number *

Banking details are transmitted securely and used solely for commission ACH payments. Never enter credentials for a shared account requiring dual authorization.

Review

Form W-9 (Request for Taxpayer Identification Number and Certification)

Complete the official IRS Form W-9 electronically. Name and address start from step 1 and can be corrected here. Your signed W-9 is stored on your profile and is not attached to staff alert emails.

1 Name (as shown on your income tax return) *

2 Business name/disregarded entity name, if different from above

3 Federal tax classification *

LLC tax classification * Enter the tax classification (C=C corporation, S=S corporation, P=Partnership). Do not check LLC if you are a single-member LLC taxed as disregarded.

Other description *

3b Has a foreign partners, owners, or beneficiaries (check if applicable)

4 Exemptions — Exempt payee code (if any)

Exemption from FATCA reporting code (if any)

5 Address (number, street, and apt. or suite no.) *

6 City *

State *

ZIP code *

7 List account number(s) here (optional)

Taxpayer identification number *

Number * 9 digits. Stored encrypted with your W-9. Never included in staff emails.

Part II — Certification. Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and (2) I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen or other U.S. person (defined below); and (4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

I certify under penalties of perjury that the information above is correct, including the Part II certifications.

Signature of U.S. person *

Sign Form W-9

Security check

After submitting, Sun Health & Dental will receive your signed agreement for countersignature. You will get a confirmation email now, and the fully executed PDF by email once both parties have signed.

Application submitted!

Your application and signed Producer Agreement were received. Sun Health & Dental will countersign next. Check your email for confirmation; the final PDF will be emailed once both parties have signed.