Social Security #: - - Tax ID #: - - Golden West Dental and Vision 2025

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering your Agent Name and Business/Firm Name in the designated fields. Ensure that all information is accurate and clearly typed or printed.
  3. Fill in your Street Address, City, State, and Zip Code. If your mailing address differs, provide that information as well.
  4. In the 'Pay commissions to' section, select whether you want payments directed to yourself as an Agent or to your Business/Firm. Enter your Social Security Number (SSN) or Tax ID Number (TIN) accordingly.
  5. Complete any additional optional information such as Email Address and Website Address if applicable. This can enhance communication regarding your application.
  6. Review all entered information for accuracy before submitting the form. Use our platform’s features to save or print a copy for your records.

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