When selecting your Broker Status, please follow the guidance below.

Broker – choose this role if you have never been certified with Connect for Health Colorado

Please ensure your last name is recorded as your registered broker license in order to receive CE credits accordingly.

The Colorado License Number field requires your Colorado License. DO NOT use your email, social security number, or National Producer Number.

Web Producer – choose this role if you are a Broker working under one of the organizations listed in the drop-down selection

* Required Field

* First Name:

* Last Name:

* Email Address:

* Work Email Address

* Phone:

* Broker Status

* Colorado License Number

Organization (Web Producers only)

* Passwords must contain both upper and lower case letters.
* Passwords must contain alpha and numeric characters.
* Passwords cannot have three or more consecutive same characters.
* Passwords must be 8 - 20 characters.
* Passwords cannot have leading or trailing spaces.
* Passwords cannot be the same as the Username, User ID, or email address.
* Passwords must contain at least one special character.

* New password

* Confirm password

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