Broker Forms and Resources

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

New York Large Group

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

Vermont Large Group

• Enrollment/Change Form - Vermont Group Plans

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

New York Small Group

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

Healthy New York

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

Vermont Small Group

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

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

New York Individual 

• Enrollment/Change Form New York Individual
• Enrollment/Change Form New York Individual Spanish

Vermont Individual 

• Enrollment/Change Form Vermont Individual

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

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

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)
• 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)
   

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