Complete the group details
Add the employer, carrier or administrator, group number, requested date and appointment scope.
For employer groups
I Want ICHRA Shop to Be My Broker.
Use this group Broker of Record letter to appoint The ICHRA Shop Insurance Agency for ICHRA, CHOICE Arrangements and employer benefits. Complete the group and carrier details, choose the scope, sign and submit it to the carrier or administrator.
Three steps
Complete, sign and submit.
The employer's authorized representative should complete the letter. Do not include employee claims, prescriptions, Social Security numbers or other sensitive health information.
Authorize the appointment
An owner, officer or other authorized employer representative signs and dates the letter.
Submit for acceptance
Send the signed letter through the carrier's or administrator's required channel and retain the acceptance confirmation.
Before you submit
Carrier requirements still control.
- Some carriers require their own Broker of Record form, a waiting period or additional signatures.
- The letter does not change coverage, bind insurance or replace carrier-specific enrollment forms.
- A separate authorization may be needed before protected health information can be disclosed.
- Confirm the effective date and acceptance with the carrier or administrator before relying on the appointment.
Want help completing the appointment?
Send ordinary group and carrier information only. We will identify the required form and submission path.