Shiftboard: Enrollment Advisors Shiftboard Registration

Benefits Educator Application

If you have not completed this form, thank you for taking a moment to complete and submit the following details.

Thank you for your patience, it might take a few hours or days until your registration has been processed.

* required field

* First Name

* Last Name

* Email

* Zip/Postal Code

* Primary or Home Phone

Mobile Phone

* Address

* Address Line 2

* City

* State/Province

Resume & Life/Health Insurance License (Please append one to the other so they are the same file)

How did you hear about DirectPath?

* Emergency Contact Name

* Emergency Phone Number

* Emergency Contact Notes

* Health Insurance

Health Type

Face-to-Face

Call Center

* Life Insurance

Life Type

Face-to-Face

Call Center

* Voluntary Benefits

VB Type

Face-to-Face

Call Center

* Medicare Supplements

MS Type

Face-to-Face

Call Center

* Affordable Care Act

ACA Type

Face-to-Face

Call Center

* Group Benefits Enrollment

GB Type

Face-to-Face

Call Center

* Name of Employer 1

* Address 1

* Employment Dates 1 (From, To)

Pay/Salary 1

* City, State, Zip Code 1

* Phone Number 1

* Job Details 1

* Name of Employer 2

* Address 2

* Employment Dates 2 (From, To)

Pay/Salary 2

* City, State, Zip Code 2

* Phone Number 2

* Job Details 2

* Name of Employer 3

* Address 3

* Employment Dates 3 (From, To)

Pay/Salary 3

* City, State, Zip Code 3

* Phone Number 3

* Job Details 3

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We appreciate your time and interest

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