bkr_agif_access_request

Annual Group Information Form - Access Request for Brokers

*Required Field

*Required Field

Group Information


 

Group Information


 

Group/Organization Name

Group/Organization Name null

Group & Sub Group Numbers You will Access

Group & Sub Group Numbers You will Access group - 8 digit number or sub group - 12 digit number null

Do you already have a web account for this group?

Do you already have a web account for this group? null

Username

Username 5-8 numbers or letters, no symbols

1st Choice for Username

1st Choice for Username 5-8 numbers or letters, no symbols

2nd Choice for Username

2nd Choice for Username 5-8 numbers or letters, no symbols

Broker Information


 

Broker Information


 

Broker Name

Broker Name First and Last Name null

Broker Phone Number

Broker Phone Number ###-###-#### null

Broker Email Address

Broker Email Address null

Agency Name

Agency Name null

Federal Tax Identification Number

Federal Tax Identification Number Also known as Employer Identification Number

Group/Organization's Authorization

Group/Organization's Authorization null

Name of Person Granting Authorization:(e.g., HR Manager or Payroll Manager)

Name of Person Granting Authorization:(e.g., HR Manager or Payroll Manager) First and Last Name null

Please allow five business days for us to process your request.  We will notify you once your web account is ready.

Please allow five business days for us to process your request.  We will notify you once your web account is ready.

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