Broker certification for the RAM Cooperative shall be administered by our third party consultant,  Health Plan Solutions. 

To submit a request for begin the certification process fill out the fields below.  For agencies looking to certify more than 5 people, please just fill out required fields.  We will utilize the agency agreement to fill in this information for the additional individuals based on the information provided in the agreement.

Once all fields are properly filled out, click on the submit button.   If it processes correctly, the page will refresh with a confirmation message and a link to the AGENCY AGREEMENT which you will need to sign and return to continue the process.

Agency Name:
Street Address:
City:
State:		- Select One -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming
ZIP Code:
Phone:		( ) -
Primary Representative/Contact:
Primary Rep Title:
Primary Rep. Phone Number:		( ) -
Primary Rep. Email address:
Additional Rep. 1 First and Last Name:
Additional Rep. 1 Title:
Additional Rep. 1 Phone:		( ) -
Additional Rep. 1 Email Address:
Additional Rep. 2 First and Last Name:
Additional Rep. 2 Title:
Additional Rep. 2 Email Address:
Is primary contact currently contracted with Fallon Community Health Plan?
yes  No
Is primary contact currently contracted with Trans America Insurance?
yes  No
Is primary contact currently contracted with Altus Dental?
yes  No
Is primary contact licensed with Health Services Administrators?
Yes. Type in broker number in "other" box..  No Other:
Is the primary contact contracted with Blue Cross Blue Shield?
Yes  No