INDIVIDUAL BROKER-OF-RECORD CHANGE FORM

By completing this form you are authorizing Blue Cross Blue Shield of Arizona (BCBSAZ) to change your Broker-of-Record currently listed on your BCBSAZ Individual Health care contract. Please complete the information requested, sign, date, and return to the address listed below.

I designate Joe M. Baselice, Broker #05345 as my Broker of record for my BCBSAZ Individual contract.

BCBSAZ Contract Holder:_____________________________________________________

Contract Holder Address:__________________________________________

                                    ___________________________________________

Contract Holder Date of Birth:_______________________________________

BCBSAZ Identification Number:_____________________________________

Daytime Phone #:__________________________________________________

Contract Holder Signature:___________________________________Date:_______________

Mail or Fax your completed form to:

Joe M. Baselice Agency, Inc.
5355 W. Chandler Blvd. #8
Chandler, AZ 85226

Fax# (480) 940-8107