SUBMISSION FORM Please return all submission documents to: dcbs.opportunity@oregon.gov Business Information of Proposers or Proposing Team Business name DBA: Address (street address) Address (Mailing Address) Primary county of operation Phone # Website License # or NPN Year business was established Number of PY 2018 Marketplace policies Locations/Service in other counties Contact information of Proposers or Proposing Team Name: Title: Phone: Email: List Agents who will be participating in the Partner Agent Program Total Number of License # Years of PY 2018 policies Name Location or NPN Experience written via the Marketplace
SUBMISSION FORM Please return all submission documents to: dcbs.opportunity@oregon.gov Business Information of Proposers or Proposing Team Business name DBA: Address (street address) Address (Mailing Address) Primary county of operation Phone # Website License # or NPN Year business was established Number of PY 2018 Marketplace policies Locations/Service in other counties Contact information of Proposers or Proposing Team Name: Title: Phone: Email: List Agents who will be participating in the Partner Agent Program Name License # or NPN Location Years of Experience Total Number of PY 2018 policies written via the Marketplace
att-a-submission-form.docx