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Request for Agent Registration

You must provide your state license number and region that is on file with your regional Kaiser Permanente Broker Relations/Administration department to begin the registration process.

IMPORTANT: If your state license is registered in ’OR’ or ’WA’ you will need to select ’NW’ as your region. If your agent ID is registered in ’MD’ or ’VA’, you will need to select ’MAS’ as your region.

If you don’t know your license number or if you have any questions, please contact:

For CA, please contact Broker Compensation Services at 800-440-2323 between the hours of
8:30 AM to 5:00 PM PT.

For all other regions, please contact Broker Shared Service Center at 844-268-2943 between the hours of
6:00 AM to 6:00 PM PT.



Your Information
*Required
Agent Information
* Region where ID is registered:
* Agent License #: