VIP Agent of Record form

Agent of Record Form
I hereby appoint the Agent/Producer listed below as Agent of Record, effective immediately, for purposes of arranging and servicing my insurance coverage for me and/or my family. This Agent/Producer and the Agency listed below may share enrollment, disenrollment, and summary plan information specific to me and/or my family, with the insurance carrier I have chosen.

I understand that the insurance agent/producer of record may receive monetary and/or nonmonetary payments from the insurance carrier listed above in connection with the purchase of the health plan coverage. This compensation does not affect the price of my insurance, which is set by the insurance carrier and approved by the Insurance Division of the State in which I live.

This appointment rescinds all previous appointments and shall remain in effect until termination by either party.

Agency: Valley Insurance Professionals

Agency NPN: 13387995

Principal Agent/Producer: Lisa Schneider

Agent NPN: 14864065
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State

Zip Code
Insurance carrier *
Participant ID (You can find this on your insurance card or a bill)
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: