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  Use the button to the left to jump to the bottom after adding multiple carriers.

Click the "Add Carriers" link for every carrier & plan, the Writing Number and every State that you are certified for and appointed in. Due to CMS guidelines, Berwick Insurance is required to have oversight on all carriers requested through the Medicare Sales System. Please ensure that all contracts requested are associated with Berwick Insurance Group LLC.

Choose appropriate values below:
Carrier & Plan Types #



Licensed & Appointed State


State License # License Expiration
   
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Add Carriers.....

By completing and submitting this form, I attest that I am licensed, certified, and appointed to sell under the terms of the carrier(s) agreements listed on the form as well as the terms of the Medicare Sales System (MSS) Agreement.

Click this checkbox to agree.

Questions? Call (888)-745-2320