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2015 Agent/Broker of Record Change Form Date of Request: Fax forms to: Group Life Dental Individual Medicare Programs Group & Individual ACA: 866-701-4991 Individual Legacy: 800-336-2429 Medicare:
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How to fill out broker of record form?
01
Obtain the broker of record form from the appropriate insurance company or regulatory agency.
02
Fill in your personal information, including your full name, contact information, and any relevant licenses or certifications.
03
Provide the name and contact information of the current broker of record, if applicable.
04
Indicate the effective date for the new broker of record.
05
If necessary, include any additional supporting documentation or attachments requested by the insurance company or regulatory agency.
06
Review the completed form for accuracy and make any necessary corrections.
07
Sign and date the form, confirming your understanding and agreement with the terms and conditions.
08
Submit the completed form to the insurance company or regulatory agency according to their specific instructions.
Who needs broker of record form?
01
Insurance agents or brokers who wish to become the broker of record for a particular client or policy.
02
Businesses or individuals who want to switch their current broker of record to a new one.
03
Insurance companies or regulatory agencies that require a formal process to appoint or change the broker of record for a specific policy or client.
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What is broker of record form?
A broker of record form is a document that designates a specific insurance broker to represent a client in their dealings with an insurance company.
Who is required to file broker of record form?
Typically, the client or policyholder who wishes to change or establish a broker relationship is required to file the broker of record form.
How to fill out broker of record form?
To fill out a broker of record form, you need to provide the client's name and contact information, the details of the insurance policy, the name of the current broker, and the name of the new broker being appointed.
What is the purpose of broker of record form?
The purpose of the broker of record form is to formally appoint a new broker and to ensure that the insurance company recognizes this appointment for all handling of the client's insurance needs.
What information must be reported on broker of record form?
The broker of record form must report the client's name, contact information, current insurance provider, details of the coverage, and identification of both the current broker and the new broker.
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