HomeMy WebLinkAboutAgent of Record Form - AT Group L� DELTA DENTAL
Agent of Record Assignment
The purpose of the Agent of Record Assignment form is to allow groups the option of selecting a
new Agency or Broker.
TO BE COMPLETED BY BROKER:
Tax I.D.# 14%"'" Oct '-1 Ili 201
Broker Name Allan Roth
Agency Name A.T. Group
Group Name (.. 0 c 1-a‘r )L \-1 Q h t S
Group Number 3 5 a co - I'd k
Effective Date 4— \- 2 4
TO BE COMPLETED BY THE GROUP ADMINISTRATOR:
"I hereby certify that the above-named Agency/Broker is to be named as Agent of Record for my
group contract and is entitled to al ommissions in return for services rendered on my behalf with
regard to my contract. This - * .tion r:4,laces all others having an earlier signature date. I
understand that if anoth- ge y/Brok; is currently servicing my account,my signature below
REPLACES that A, cy/Bro er"
Print Name �l ��,i NS 0 ti C/ �is_M&Th�
Signature /011•12willirr
Date 3—1 J
All agent of record requests must be on this form. Forms will be returned if not fully completed.
The effective date of the agent of record change will be the first of the month following the date
of the change request.
SUBMIT TO:
Delta Dental of Minnesota
P.O.Box 9304
Minneapolis,MN 55440-9304
ATTN:DELTA DENTAL CONNECT
or
Fax: 651-406-5937
E-mail: deltaconnect(adeltadentalmn.org
Phone: 651-406-5920