Superior Dental Care Secure Form
Use this form to become an SDC-appointed producer.
PRODUCER APPOINTMENT INFORMATION FORM
Agency Name:  
(Commission will be paid to the agency listed)
Agency Tax ID:  
Agency NPN:  
Agency Licensure Number:  
Agency Address:
Street Address:  
City:  
State / Zip   /  
Agency Phone Number:  
Agency Fax:  
First Name:  
Middle Name:  
Last Name:  
Social Security Number:  
Email:  
NPN#:  
Resident State:  
DOI#:  
Date of Birth:    
By entering my initials in the box below, I certify that I am an authorized representative of the company identified on this form and that any information submitted is accurate and current.
Initials:  


If you are submitting your information as a new firm and/or a new AOR, please use our Document Upload to send us a copy of the firm's license and/or a copy of the agent's license.