Online Enroll & Access Request Form for Broker

Please complete all fields and click "Submit".
We protect the privacy of your message with SSL encryption (opens a tooltip).

Group Information


Group / Organization Information*

(Include subgroup numbers with no dashes or spaces.)

Existing Group Web Account*

5-8 numbers or letters, no symbols, special characters, or spaces.

Broker Information


Group / Organization's Authorization:

Please review then continue

  • 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).Opens a PDF

Name of Person Granting Authorization:


e.g. Human Resources Manager or Payroll Manager.

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