Broker of Record Letter
Insurance company Name
City, State zip
This letter is a request to change our broker of record for our health insurance
through Blue Cross.
Pleas assign “Lori Hernandez” as our primary broker. We would like to make
this change effective as of ---/----/---. Please provide Lori Hernandez with a
copy of any renewal or additional information she might need to service our
Should you have any questions please feel free to call Lori Hernandez @ 909-
598-4565 or me directly at ____________ anytime.
Thank you for your help and assistants in this matter.
___________________ _____________ _______________
(signature) title date