Missouri Banner
 

Missouri Application

Thank you for your interest in marketing our dental plans. Contracting with us is a simple process by following the steps below:

Step 1: Agent Agreement

  1. Complete the Agent Agreement (fillable form), which includes the Business Associate Agreement and Non-Disclosure Statement.
  2. Print the completed Agent Agreement.
  3. Complete the Non-Disclosure Statement section (fillable form). The “Contractor” name in the first sentence must be the Legal Name (shown on your income tax return) as it appears on Line 1 of your IRS Form W-9. Have an officer of your company sign where indicated.
  4. Sign where indicated.

Step 2: Obtain a copy of your MO Insurance License

Step 3: IRS form W-9:

  1. Complete a Department of the Treasury Internal Revenue Department Form W-9 (fillable form).
  2. Print the completed W-9 form (page 1 only)
  3. Sign where indicated

Step 4: FFM User ID and Exchange Training Certification

  1. Include a copy of each of these documents to enroll groups on Healthcare.gov
 
 
Once you have compiled, completed and signed the above documents, please send ALL to:
LIBERTY Dental Plan
Attn: Client Services
P.O. Box 26110
Santa Ana, CA 92799-6110
Fax: (949) 270-0114
 
Email:clientservices@libertydentalplan.com. Because the documents include your private information, please send them encrypted or password protected.

Once we receive and approve all of the completed documents, you will receive a notification that you are contracted with LIBERTY Dental Plan. Included will be executed copies of your Agent Agreement and your assigned Broker/Agent number. We are unable to pay any commissions until all of these documents have been completed, received and approved.

If you have any questions regarding this process, please contact our Client Services Department at (888) 273-2997 x162.

LIBERTY Dental Plan (“LIBERTY”) requires its Agents/Brokers who may, in the course of providing services for LIBERTY, have access to members’ Protected Health Information (PHI) to execute a Business Associate Agreement (BAA) and any updates thereto. The Business Associate Agreement sets forth all applicable privacy and security requirements under the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”) and Health Information for Economic and Clinical Health Act (“HITECH Act”). In addition, LIBERTY requires its Agents/Brokers who may have access to its (or its clients’) confidential information to execute a Nondisclosure Agreement (NDA) and any updates thereto.

We look forward to working with you to provide
quality dental benefits to your clients!