Producer Registration Form  

All producers must be licensed and appointed prior to representing ConnectiCare, Inc. and/or registering online. Click here for information regarding the appointment process.

Please provide the following information (all fields are required):     *   =   Required

*First Name: 

*Last Name: 

*Email Address: 

*Select Username: 

(Any combination of letters and numbers with no spaces. Must be at least 6 characters.)

*Select Password: 

(Password is case sensitive. Must be at least 6 characters. May contain letters and numbers.)

*Retype Password: 

*Producer License Number:

(Provided by the state of CT, MA or NY.) License number may contain 9 digits. Add preceding zero’s as needed (e.g. 009999999).)

*Tax ID:
(Social Security Number) 

(Example: 045123456) HELP