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, One Federal Street, Suite 700, Boston, MA 02110   Attention:  James McCarthy.

The Commonwealth of Massachusetts Division of Insurance uses the NAIC OPTins System for receiving electronic payments.  OPTins is a web application that is available to users 24 hours, 7 days a week. OPTins is a reliable and inexpensive way to submit payments electronically.  The Division requires that when making a payment a tracking number be used along with a state received date.  Groups can also include an image of an OPTins payment with the application.