| Agent's First Name |
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| Agent's Last Name |
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| Oklahoma License Number |
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| Agency Name |
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| Address |
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| City |
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| State |
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| Zip Code |
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| County |
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| E-Mail |
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| Telephone Number |
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| Fax Number |
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Agency/Agent
Website Address
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4 Hour CE Course
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Location
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Date Of
CE Course
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1.
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4 Hour CE Test
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Location
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Date Taken
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Score %
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1.
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2.
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Employer Groups
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Submit first 3 Employer Groups through an Outreach Coordinator |
First and Last Name of Outreach Coordinator |
Contact Method |
1.
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2.
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3.
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| ESI |
Successfully signed up 5 IO Employer Groups |
FEIN |
E# (E0000xxxx) |
1.
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2.
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3.
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4.
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5.
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| Contract |
Must have signed legal agreement on file |
Date submitted |
E-Mail/Fax |
1.
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E-Mail Fax |
| Comments |
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www.insureoklahoma.org
helpline: 1-888-365-3742
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