AOR Form

Agent of Record Change Request Form
Please provide the required information below. Incomplete forms will not be accepted.
1. Group Information
Group Name:
Address:
City:
State:
Zip:
Group Number:
2. Change Request
Please be advised that we wish to appoint the agent below as the agent of record for our
group policy.
Agency Name:
Address:
City:
State:
Zip:
Agent Name:
Effective Date:
**Please note, by signing and submitting this document to BCBSNE, you are indicating to BCBSNE
that the relationship with the current agent of record has been terminated. The agent named in Section
2 of this form will assume all agent responsibilities on the requested effective date. The newly
appointed agent will be eligible to earn commissions the first of the month following the receipt of the
completed form.**
3. Signature
(Signature of Group Decision Maker)
(Date)
(Title of Group Decision Maker)
Please return your completed form to the following address:
BlueCross BlueShield of Nebraska
ATTN: Underwriting Services
P.O. Box 3248
Omaha, NE 68180-0001
Fax: 402-548-4690
Email: [email protected]