Agent of Record Change Form (Individual)
Please Do Not use this form for any Medicare products
This is to certify that (agent name)___________________________________ has been appointed as agent of record for the
policyholder named below, for matters relating to health, dental and vision. This appointment is continuous until another agent is
designated by this policyholder.
In its discretion, Regence BlueShield of Idaho shall accept the change and notify the client, the incumbent and new agent of this
change and its effective date. The effective date of the change will be the first of the following month provided the request is received
by the 25th of the month.
Please review Important Notes below.
POLICYHOLDER INFORMATION
Policyholder’s Printed Name
Policyholder’s ID number (if unknown, please provide DOB and Address or Application ID)
Policyholder’s Signature
Date
(mm/dd/yyyy)
AGENT INFORMATION
New Agent Name
New Agent’s ID Number
Current Agent *(if known)
Current Agent ID *(if known)
Send Request to:
Email
Secured Fax
[email protected]
(888) 734-3807
Subject: AOR Request
Attn: AOR Request
Important Notes:
1. Requests must be received by the 25th of the month for an effective date of the 1st of the following month. If received after
the 25th they are effective the 1st of the next month.
2. AORs must be signed by the policyholder.
3. The new agent must be appointed with Regence BlueShield of Idaho.
4. All fields are required except *(if known). Incomplete forms may be returned for completion.
5. A letter signed by the policyholder will be accepted if it contains all required information.
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