Form 3-037 - Individual Agent Of Record Form - Blue Cross Of Idaho
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1Individual Agent of Record Form
For individual and family insurance plans only, not intended
for Medicare Advantage or group lines of business
To ensure the agent you use is listed as the agent of record on your account, please fill out this form
and return it to Blue Cross of Idaho at or fax 208-286-3594
Medical Enrollee #: __________________________ Dental Enrollee # (if different): ____________________________________
Enrollee Name: _______________________________________________ Date of Birth ______________________________
Address: ________________________________________________________________________________________________
Enrollee Phone #: ____________________________ Email Address: _________________________________________________
Reason for Change: _________________________________________________________________________________________
Please be advised that I wish to appoint: __________________________________________ (agent name) as my agent
of record effective __________________ (date). This form officially places the agent listed above in the role of liaison,
representing your individual health insurance policy through Blue Cross of Idaho. It transfers commissions to the agent
listed above and removes any current or previous agent as your agent of record.
_____________________________________________________________________________________________________
Enrollee’s Signature
Date
_____________________________________________________________________________________________________
Enrollee’s Printed Name
To be completed by new Agent of Record:
As the new agent, I accept the assignment of the above named individual as their agent of record.
I further certify that all the information shown above is correct and complete to the best of my knowledge.
Agent’s Printed Name
Agent’s Signature
Agent’s Blue Cross ID Number
Idaho License Number
Email Address
Agent’s Phone Number
Date
The Agent of Record (AOR) change is effective the first of the following month following receipt of the completed form.
For on-exchange enrollment, you must update the AOR with both Blue Cross of Idaho and Your Health Idaho.
Form No. 3-037 (11-15)
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