How To File An Application For Registration As A Purchasing Group

Please download the form below and save it.  You can then edit the fillable form and save it as many times as you need until you are happy it is complete.  You can also print it as many times as you like.  Please perform these functions using the buttons towards the end of the form. You will need Adobe Reader to perform these functions.

If you are strictly amending, there is no fee for an amended application.

If this is the group’s initial application, it must attach a certificate appointing the Commmissioner of Insurance as its attorney to receive service of legal process issued against it in the commonwealth. The appointment must be irrevocable, shall bind any successor in interest, and shall remain in effect as long as there remain any obligations or liabilities of the group.

Please note that a non-refundable filing fee of $125, payable to the Commonwealth of Massachusetts, must accompany every annual application. (Except an amended annual application) Please email copies of all completed signed documents and copy of check to james.a.mccarthy@mass.gov.  Then mail check with completed application to the Division of Insurance, 1000 Washington Street, Suite 810, Boston, MA 02118-6200   Attention:  James McCarthy.