Forms and Guides for Brokers

Agent of Record Designation (AOR) Form

• 2019 SEP Individual Plan AOR form (online)

Applications

• Application for Health Coverage and Help Paying Costs - DHS-6696-ENG (PDF)
• MNsure Application for Health Coverage - DHS-6741 (PDF)
• Account Request Form (PDF)

Miscellaneous Forms

• Broker Case Status Request Form (Excel)
• Federal Tax Information (FTI) Form (PDF)
• Employer Health Coverage form-Appendix A (PDF) (for employees who enroll in individual coverage and whose employer offers small group coverage)

Report a Change

• Report Application Changes
• Avoiding Common Errors in Reporting Life Events (PDF)

Special Enrollment Periods

• Qualifying Life Events
• Special Enrollment Period and Pre-enrollment Verification Guide for Assisters 2019 (PDF) (updated 1-2019)
• Verification documentation cover letter
• Verification document upload site