CREDENTIALLING INFORMATION REQUIRED

To receive commissions for new sales please complete the following information and return it to us:

• Broker Agreement* (pdf)
• Copies of License (Massachusetts)
• W-9 / Request for Taxpayer ID* (pdf)
• Standard Broker Information Sheet
• Copy of Declaration Page of E & O Policy
• Broker Compensation Electronic Funds Transfer Form (EFT)* pdf

Please mail this information to:

Health New England
Attn: Jennifer Murray, Broker Relations Liaison
One Monarch Place Suite 1500
Springfield MA 01144-1500

If you have any questions, please contact
Jennifer Murray, Broker Relations Liaison, at 800-842-4464, Ext 3380.

*Please click on the form that you need and it will open in PDF format so you can print it.
If you need acrobat reader please click here to download it.