2024-12-12
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Broker Registration
Personal Information
First name *
Please provide a first name.
Last name *
Please provide a last name.
Date of Birth *
Please provide a date of birth.
Email *
Please provide a email address.
NPN *
Please provide a NPN.
Broker Agency Information
NOTE: If you are not associated with a broker agency, please enter your personal information. Do not enter a General Agency or Third Party Administrator‘s Information.
Legal Name *
Please provide a legal name.
DBA
Practice Area *
Select Practice Area
Small Business Marketplace ONLY
Please select a practice area.
Select Language(s)
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Xhosa
Hold Ctrl or Command (mac) to select multiple
EVENING/WEEKEND HOURS?
ACCEPT NEW CLIENTS?
ACH Routing Information
Account Number *
Please provide an account number.
Routing Number *
Please provide a routing number.
Routing numbers dont match
Routing Number Confirmation *
Please provide routing number confirmation.
Routing numbers dont match
Office Location
Address *
Please provide a valid address.
Kind *
Primary
Mailing
Branch
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Address 2
City *
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State *
SELECT STATE
AK
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DE
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MD
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OR
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Zip *
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Phone
Area Code *
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Number *
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Add Office Location
By submitting this application to become a certified broker on the Health Connector for Business, I agree to the terms and conditions described in the
Massachusetts Health Connector Broker Agreement
.