Valley Insurance Professionals Agent of Record Form

Agent of Record Change Form

Valley Insurance Professionals
Reason for Agent of Record (required):

To assist with the administration of Healthcare Cost Assistance Benefits, in partnership with Carewell SEIU 503 Benefits and funded by the Oregon Homecare Workers Supplemental Trust.

This is a request to assign the above-named agent as the Agent of Record for the policyholder named above. This appointment removes any prior agent and is continuous until another agent is designated by the policyholder. This Agent and the Agency listed above 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 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. I further understand that if I would like more information on how compensation is calculated, I can read more in the Valley Insurance Professionals Notice of Privacy Practices. I may also call them directly at 503-480-0499 for more information.

Agency: Valley Insurance Professionals

Agency NPN: 13387995

Principal Agent/Producer: Lisa Schneider

Agent NPN: 14864065
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Insurance carrier*
Participant/Member ID (You can find this on your insurance card or a bill)
Signature*

Clear
Date*

MonthDayYear
Date
If you have questions about this form, you can call the Carewell SEIU 503 Benefits Team at 1-844-503-7348.

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Agent of Record Change Form