Broker Forms and Resources

• Employer Large Group Size Attestation (PDF)
• Employer Large Group Size Attestation (Fillable) (PDF)
• Grandfathered Plan Status Certification (PDF)
• Grandfathered Plan Status Certification (Fillable) (PDF)
• Independent Contractor Attestation (PDF)
• Independent Contractor Attestation (Fillable) (PDF)
• Large Group HMO Attestation (PDF)
• Large Group HMO Attestation (Fillable)  (PDF)

New York Large Group

• Enrollment/Change Form—New York Large Group (PDF)
• Enrollment/Change Form—New York Large Group (PDF)—Spanish
• New York Large Group Billing and Contact Form (PDF)

Vermont Large Group

• Enrollment/Change Form - Vermont Group Plans (PDF)

• Affidavit of Group Sponsored Coverage for Common Law Employees (PDF)
• Affidavit of Group Sponsored Coverage for Common Law Employees (Fillable) (PDF)
• Attestation for Eligibility For Small Group Products (PDF)
• Attestation for Eligibility For Small Group Products (Fillable) (PDF)
• Grandfathered Plan Status Certification (PDF)
• Grandfathered Plan Status Certification (Fillable) (PDF)
• Independent Contractor Attestation (PDF)
• Independent Contractor Attestation (Fillable) (PDF)

New York Small Group

• Enrollment/Change Form—New York Small Group HMO (PDF)
• Enrollment/Change Form—New York Small Group HMO (PDF)—Spanish
• Enrollment/Change Form—New York Small Group EPO/PPO (PDF)
• Enrollment/Change Form—New York Small Group EPO/PPO (PDF)—Spanish
• New York Small Group Application HMO (Fillable) (PDF)
• New York Small Group Application EPO/PPO (Fillable) (PDF)
• New York Small Group Recertification Form (PDF)
• New York Small Group Recertification Form (Fillable) (PDF)

Healthy New York

• Enrollment Change Form Healthy New York (PDF)
• Enrollment/Change Form Healthy NY -Spanish (PDF)
• Healthy New York Small Group Application (PDF)
• Healthy New York Small Group Recertification Form (PDF)
• Healthy New York Small Group Recertification Form (Fillable) (PDF)

Vermont Small Group

• 2025 Vermont Small Group Plan Selection Form (PDF)
• 2025 Vermont Small Group Plan Selection Form (Fillable) (PDF)
• 2024 Vermont Small Group Plan Selection Form (PDF)
• 2024 Vermont Small Group Plan Selection Form (Fillable) (PDF)
• Enrollment/Change Form Vermont Group Plan (PDF)
• Vermont Small Group Application Form (Fillable) (PDF)
• Vermont Small Group Recertification Form (PDF)
• Vermont Small Group Recertification Form (Fillable) (PDF)

• 2025 Individual HSA Enrollment Packet (PDF)
• One-Time Direct Payment Form (Fillable) (PDF)

New York Individual 

• Enrollment/Change Form New York Individual (PDF)
• Enrollment/Change Form New York Individual Spanish (PDF)

Vermont Individual 

• Enrollment/Change Form Vermont Individual (PDF)

See below for forms related to individual and employer group Medicare plans.

• Authorization to Disclose Information (ADI) Form (PDF)
• Medicare Part D Comprehensive Formulary (PDF)
• Medicare Advantage Certification Course (PDF)
• Plan Recommendation Tool
• Scope of Sales Appointment Confirmation Form (Static) (PDF)

Online Enrollment Tools

• MVP DualAccess (HMO D-SNP)
• MVP Medicare Advantage and UVM Health Advantage plans

Plan Year 2025

Medicare Star Ratings

• MVP Medicare Secure (HMO-POS), MVP Medicare Secure Plus (HMO-POS), MVP Preferred Gold with Part D (HMO-POS), MVP Preferred Gold without Part D (HMO-POS), and MVP DualAccess (HMO D-SNP) (PDF)
• MVP WellSelect with Part D (PPO), MVP WellSelect Plus with Part D (PPO), MVP Medicare Patriot Plan (PPO), UVM Health Advantage Preferred, Secure, and Select with Part D (PPO) (PDF)
   

• Medicare Advantage Employer Handbook (PDF)
• Medicare Advantage Certification Course (PDF)
• Medicare Broker of Record Letter (PDF)
• Medicare Group Comprehensive Part D Formulary (PDF)