Broker of Record Letter
RE: INSURANCE CARRIER: ____________________________________________________________
Client Name: _______________________________ Client/Policy Number: ______________
The client above has named SWIFT KENNEDY & ASSOCIATES as Producer(s) of Record effective immediately for its group health care benefits offered through above carrier and applies to all lines of business unless otherwise stated. This Producer of Record Letter will remain in effect until carrier is notified via a revised Producer of Record Letter, or the Client's Health Benefits Plan contract is terminated. In addition, Client hereby acknowledges and agrees that carrier may disclose enrollment, disenrollment, summary health and/or premium billing information, benefit booklets, executed administrative services or insurance contracts requested by the Producer of Record for purposes of inputting, updating and/or reviewing the same for the above identified business.
Client recognizes that the Producer(s) of Record, as indicated above, acts as representative(s) for carrier in accordance with applicable carrier agreements. It is understood that the named Producer(s) of Record will receive commissions in consideration for the services provided. The Producer(s) of Record may be eligible to receive additional compensation for achieving specified sales goals.
Signature of Authorized Representative of Client Date
Print Name if Authorized Representative of Client Title
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