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Get Broker Of Record Letter Sample

Colorado Broker of Record Authorization Form Please submit this completed form by e-mail or fax to Kaiser Permanente Distribution Channels Broker Relations Department Licensing Commissions at CO-BrokerComp kp.org or Fax 303-496-0761 For additional information or assistance contact the Commission s Department at 303-306-2547 We the undersigned group hereby request to designate the insurance broker named below as our authorized insurance broker/consultant for Kaiser Foundation Health Plans. By submitting this request we authorize you to provide our group plan information to our designated broker/consultant so that s/he may conduct business on our behalf this information includes but is not limited to our group plan agreement rates benefit and payment information. This letter supersedes any agreements previously issued by our company to Kaiser Foundation Health Plan Inc. This authorization shall remain in effect until such time as it is rescinded in writing. Colorado Broker of Record Authorization Form Please submit this completed form by e-mail or fax to Kaiser Permanente Distribution Channels Broker Relations Department Licensing Commissions at CO-BrokerComp kp*org or Fax 303-496-0761 For additional information or assistance contact the Commission s Department at 303-306-2547 We the undersigned group hereby request to designate the insurance broker named below as our authorized insurance broker/consultant for Kaiser Foundation Health Plans. By submitting this request we authorize you to provide our group plan information to our designated broker/consultant so that s/he may conduct business on our behalf this information includes but is not limited to our group plan agreement rates benefit and payment information. This letter supersedes any agreements previously issued by our company to Kaiser Foundation Health Plan Inc* This authorization shall remain in effect until such time as it is rescinded in writing. We understand that ONLY FULLY APPOINTED KAISER PERMANENTE BROKERS ARE ENTITLED to receive commissions or fees and service allowances in conjunction with the placement installation and/or servicing of our insurance contract/agreement. Employer Group Contact Information Broker Contact Information Group name Date of request Group number Vendor number NPN number Broker phone number Broker fax number Group phone number Group e-mail address Broker e-mail address Group contact signature Broker signature Broker printed name Broker agency name Broker commission rate Method Please complete all fields e-mail address is required for confirmation Once the signed BOR is received the effective date will be the first day of the month following receipt of the BOR* Commissions will be paid only to brokers who are appointed with Kaiser Permanente. Commission payments can only be made after appointment is complete and no payment will be made in arrears. Received by Date Signed Effective date Existing vendor New vendor MSGU Large group broker commission rate change Y or Date to Membership Admin* 10CBOR-Form2 N MSSU Contact previous vendor LG / SG Contact new vendor Callidus KPSC.

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