Forms

Small Business:

Broker Form

Please fill out the New Broker Profile form to establish you and or agency on the beWellnm website as a resource to the community, and provide you the ability to receive referrals. If you are interested in providing Small Business coverage with beWellnm as part of your services, this form will assist in creating a profile in our training system for any future CE courses and to secure certification in the beWellnm Small Business Health Option. As well as our Small Business Health Options benefit, enrollment and employee and employer portal. This will allow an Small Business owner to select you as their broker as they are creating their account and coverage in the beWellnm Small Business Portal.

Broker Profile Change Form

Please fill out the form to notify beWellnm regarding a change, such as address, phone, website, product offering or a change in your business. Such, as moving to another agency. Or establishing your own agency.

Broker of Record

Complete this form to ensure the correct broker is reflected as the Broker of Record (BOR) on new or existing business. This form must be signed by both the broker and the Company Owner and/or designated Administrator.