Agent Broker Letter Of Record printable pdf download

Agent Broker Letter Of Record

AGENT/BROKER L ETTER O F R ECORD

November 2 8, 2 015

Regence B lueCross B lueShield o f U tah P O B ox 3 0270

Salt L ake C ity, U T 8 4130-‐0270

RE: C lient N ame _ ________________________ P olicy#______________________________

Dear R egence B lueCross B lueShield o f U tah:

I, _ ________________ h ereby d esignates M ark B locker a s A gent o f R ecord E ffective 1 2/01/2013 w ith r espect t o

the i ndividual m edical i nsurance p olicy s he h as t hrough R egence B lue C ross B lue S hield.

Any q uestions a bout o ur c overage o r p roposed b enefit c hanges, a s w ell a s a ny f ees a nd c ommissions, s hould b e

directed t o:

Mark B locker 1 776 P ark A venue # 442 P ark C ity, U T 8 4060 A gent # : 0 105891-‐0000

This A gent L etter o f R ecord r escinds a ny p rior a ppointment o f a gent o r a gency w ith r espect t o t his c overage a nd

shall r emain i n e ffect u ntil r evoked o r r eplaced i n w riting.

Sincerely,

Client:

Signature

Date N ame

(printed)

Authorized a gent/agency o fficial

Agent # :

Date S ignature

0105891-‐0000

e-‐mail: r

fax: 8 01-‐333-‐2671 A ttn: R egina E ssex

Agent Broker Letter Of Record