Off-exchange IFP and Medicare
Supplement plans producer of
record change request
Use this form to request a change to your producer of record on file for Medicare Supplement
plans and off-exchange Individual and Family Plans only.
Complete all fields and submit this form to one of the contacts listed below:
• Fax: (209) 371-5830
• U.S. mail: Blue Shield of California, P.O. Box 3008, Lodi, CA 95242
• Email: firstname.lastname@example.org
ber name: Subscriber ID#:
Tax ID#: Requested effective date:*
By signing below, I acknowledge that I am appointing the above-referenced producer as
my insurance representative with respect to coverage provided by Blue Shield. The above-
referenced producer is authorized to act on my behalf.
This designation will remain in effect until Blue Shield is notified otherwise in writing with this form.
Name of subscriber Signature of
Signature of accepting broker Date
Blue Shield of California, an independent member of the Blue Shield Association A44674-FF (8/15)
* Producer of record change will take effect on the 1st day of the month following the date of receipt unless a future date is specified.