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
APPLICANT INFORMATION
 

ADDITIONAL INFORMATION
* Resident State and License Number
National Producer Number
* Date of Birth
Fluent Languages
ASL (Sign Language)
Arabic
Chinese
Creole
Dutch
Farsi
Finnish
French
German
Greek
Hebrew
Hmong
Indian (Hindi/Urdu/Misc)
Italian
Japanese
Polish
Portugese
Russian
Spanish
Somali
Swedish
Tagalog
Thai
Vietnamese
Other
How did you hear about DirectPath?
Emergency Contact Information
* Emergency Contact Name
* Emergency Phone Number
* Emergency Contact Notes

License Information (Check all the apply)
Non-Residence License
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY

Insurance Sales/Enrollment Experience
* 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

Please list your work experience for the past five years beginning with your most recent job held.
Job 1
* Name of Employer 1
* Address 1
* Employment Dates 1 (From, To)
Pay/Salary 1
* City, State, Zip Code 1
* Phone Number 1
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
* Job Details 1
Job 2
* Name of Employer 2
* Address 2
* Employment Dates 2 (From, To)
Pay/Salary 2
* City, State, Zip Code 2
* Phone Number 2
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
* Job Details 2
Job 3
* Name of Employer 3
* Address 3
* Employment Dates 3 (From, To)
Pay/Salary 3
* City, State, Zip Code 3
* Phone Number 3
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
* Job Details 3



We appreciate your time and interest


 
 
Birmingham, Alabama 35233
205.380.9487
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