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Request for Registration

Please enter the following information to begin the registration process.

IMPORTANT: You must provide the same broker/agent ID and region that is on file with your regional Kaiser Permanente Broker Relations/Administration department. If your broker/agent ID is registered in 'OR' or 'WA' please select 'NW' as your region.

If your broker/agent is registered in 'CO', “Please enter your Colorado Kaiser Permanente assigned six digit broker vendor number in the Broker/Agent ID. If you do not know your vendor number please contact your local Regional Marketing Consultant.”

The email address entered will be used to send messages necessary in completing the registration process.

Your Information
Broker/Agent Information
* Broker/Agent ID:
* Region where ID is registered:
* Email: