Insurer UMG Primary Administrator Application

Use this form to apply to become an Insurer UMG Primary Administrator for a new UMG. Once you have completed the form, press the "Submit" button to apply. You will receive a link to a printable version of the form, along with further instructions.

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Insurer UMG Primary Administrator Information

Request New Carrier UMG (User Management Group)

 NOTE: The ability to change the current Primary Administrator's contact information or assign a new Primary Administrator to an existing UMG is available to logged-in users via the Admin menu item.

New Carrier
NOTE: Creating a new Carrier is not necessary if you are requesting a new UMG/Carrier Group in order to move an existing Carrier into it.

New User Existing User

Applicant Information


Carrier Information


Authorizing Officer

By submitting this form, you agree to abide by all Terms and Conditions (PDF download).
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