Certified Insurance Agent Storefront Location Application

Certified Insurance Agent Storefront Program

Application

Primary Certified Insurance Agent Contact*

*

Primary Certified Insurance Agent License Number*

Name of Agency*

Physical Location*

*

Physical Location County*

Storefront location for Open Enrollment*

Physical Location address is my Open Enrollment office space

In addition to my Physical Location, I plan to open a New Location for Open Enrollment

Mailing Address (optional)

Mailing County (optional)

Phone Number for Public Use*

Phone Number for Covered California Use*

E-mail Address for Public Use*

E-mail Address for Covered California Use*

Website Address

Languages Spoken*

DESCRIPTION

How many seats are available in the reception/lobby area for consumers?*

How many private offices/cubicles are available for private enrollment?*

What is the square footage of the office?*

How many years has your agency been in business?*

How many Covered California policies has your agency written?*

Is insurance and financial services your lead line of business?*

Yes

No

Is more than 50% of your business health insurance?*

Yes

No

Do you offer enrollment assistance in Covered California’s small group market?*

Yes

No

Office View*

Office suite NOTvisible from the street

Office building visible from the street

Retail space in a shopping center

Other

Parking Availability*

Free parking

Street parking

Paid parking

Other

AGENTS

List all of the licensed agents that will be providing assistance at this storefront location. There are 10 fields available. If extra fields are needed, submit a list of the remaining agents and license numbers.

DAYS & HOURS OF OPERATION

Check the boxes next to the days this storefront will be open to the public. Use the dropdown feature to indicate the hours of when the storefront opens and closes for each day.

To indicate a date closed, leave the hours of operation at Open 1AM and Closed 1AM.

PHOTO ATTACHMENTS

When submitting your storefront application, you are REQUIRED to submit photos.

Please email the required photos to storefront@covered.ca.gov and include the name and address of your storefront as it appears on the application.

Photos should display a clean, safe and professional environment. A photo of the office building interior must be without clutter or potential hazards to consumers. At least one of the exterior photos MUST have the Covered California co-branded logo and include the language Enroll Here on your signage.

Photo Image Requirements:

Photos must be horizontal (landscape)
Must have a .JPG, .PNG, or .GIF extension
File size must be less than 3MB.

Required: At least 1 exterior photo of the storefront building displaying signage in place
Required: At least 1 interior photo of the storefront building displaying an area where consumers can receive assistance

SUBMISSION

Applications will be reviewed and only those who have submitted a complete application and are qualified will be selected. Covered California seeks to provide adequate storefront coverage in all rating areas and based on geographic need.

By submitting this application, you hereby attest that:

You are an insurance agent who is currently certified with Covered California via: http://hbex.coveredca.com/agents/training/
You have read, understand, and agree to the guidelines.
You have the authority to enter into this agreement on behalf of your organization.
All information provided herein is complete and accurate and you will notify Covered California of any changes.
You grant Covered California the authority to use your name, your company name, and a photograph of your organization on Covered California’s website.
You will remain in compliance with all applicable agreements and regulations pertaining to your certification with Covered California throughout the term of this program.
You understand that Covered California reserves the right to accept or reject any application if it does not meet the criteria outlined herein, or for other reasons not included in the program guidelines.

*NOTE: If you are not selected to be listed on the Covered California website, Covered California still encourages you to use co-branded signage to promote in-person assistance. This is a very effective way for Agents to create awareness within their community and increase their walk-in traffic. After an application has been submitted, you will receive an e-mail within 2-3 business days to inform you of the acceptance or denial of the application.

If you have any questions regarding this program please send an email to: Storefront@covered.ca.gov

I declare under penalty of perjury that the foregoing is true and correct.

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