Individual Agent of Record (AOR) Change/Add
Completion of this form will remove any prior agent from your policy, if applicable.
Member Name (please print clearly)
Member ID
(9 digit number on your member card)
Please change/add the agent on my BridgeSpan Health policy.
Reason/Comment:
No current agent
Consolidating other coverage with same agent
This agent is geographically closer
Other (use lines below)
Other:
Member’s Signature
Date
New Agent’s Name
New Agent’s ID Number
(example: 0000123-0001)
New Agent’s Email Address
By signing this form, I state that I am appointed with BridgeSpan Health. If not, I acknowledge that I will
forfeit commission until appointed.
New Agent’s Signature
Send requests to:
Fax:
Email:
(855) 639-3935
[email protected]
ATTN: AOR Request
ATTN: AOR Request
1.
2.
3.
4.
All change/add requests must be signed by the policy holder.
The new agent must be appointed with BridgeSpan Health and be certified to represent the health coverage product the policy
holder is on.
Any changes received by the 15th of the month will be effective the first of the following month. Any change received on or after the
16th of the month will extend to the first of the month following the next month.
In the event we cannot accept this request, the current agent will not be removed from your policy.