Qualified Agent Form Agent's First Name Agent's Last Name Oklahoma License Number Agency Name Address City State Zip County E-Mail Telephone Number Fax Number Agency/Agent Website Address Employer Groups Submit first 3 Employer Groups through an Outreach Coordinator First and Last Name of Outreach Coordinator Contact Method 1. Face-To-Face E-Mail Fax 2. Face-To-Face E-Mail Fax 3. Face-To-Face E-Mail Fax ESI Successfully signed up 5 IO Employer Groups FEIN E#(E0000xxxx) 1. 2. 3. 4. 5. Contract Must have signed legal agreement on file Date submitted E-Mail/Fax 1. Yes No E-mail Fax Comments     www.insureoklahoma.org helpline: 1-888-365-3742