Broker Of Record Form - Not Empire Blue Cross Blue Shield:
Re:        Broker of Record Transfer
Group Name:
Group Policy Number:
Health Insurance Carrier:
Please assign _____William P. Zacharias, AAMS____________ as Broker of Record
and P.G.P. ( thebenefitsweb.com ) as General Agent on the above referenced policy
effective immediately.
Sincerely,
___________________________________
Group Benefits Administrator
***Signature Required***
Please Print , Sign & Return via FAX To:
 1-516-486-8212
BusinessBenefitSolutions.com