bor empire

Broker of Record Letter - Empire Blue Cross Blue Shield ONLY:

BusinessBenefitSolutions.com

Re: Broker of Record Transfer

Group Policy Number:

hereby designates the broker/consultant(s) listed below at the commission percentage
split indicated as the broker/consultant(s) of record (the “BOR) for the Group. Further,
the Group hereby authorizes Empire HealthChoice Assurance, Inc. and/or Empire
HealthChoice HMO, Inc. to send all quotes, policies and notices to the BOR. The Group
hereby acknowledges and agrees that notice to the BOR is notice to the Group.
This BOR designation shall remain in effect until it is expressly terminated by the Group in
writing.

BOR Designation: Please insert broker/consultant(s) name(s), address(es), and the
applicable commission percentage split below.

Broker/Consultant(s) Name and Address                        Commission % Split
1.      William P. Zacharias, AAMS                                                100%
        PO Box 25
        Franklin Square, NY 11010
        888-743-4222

____________________________________

Signature

1-516-486-8212

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