CREDENTIALLING INFORMATION REQUIRED

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

• Broker Agreement
• Copies of License (Massachusetts)
• W-9 / Request for Taxpayer ID
• Standard Broker Information Sheet
• Copy of Declaration Page of E & O Policy

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.