Online Enroll & Access Request Form for Broker

*Required Field

Group Information


Group/Organization Name

Group & Sub Group Numbers You will Access

Do you already have a web account for this group?


1st Choice for Username

2nd Choice for Username

Enroll/Update Access

Broker Information

Please Note:  Broker name and email address must correspond to the same person.

Broker Name

Email Address

Phone Number

Agency Name

Federal Tax Identification Number

Group / Organization's Authorization


  • The group administrator named below understands that the broker named above will have access to protected health information of members enrolled in their group/organization's health insurance programs, made available through the Health Plan's online service center.
  • The access is necessary in order to perform certain administrative functions.
  • The group administrator named below has consented to the following additional Plan Sponsor’s Designation of Appointed Broker - Terms of Access/User (PDF)

Authorization Agreement

Name of Person Granting Authorization:(e.g., HR Manager or Payroll Manager)

Please allow five business days for us to process your request.  We will notify you once your web account is ready.