Agent of Record BCBS

Arkansas Blue Cross and Blue Shield Agent of Record Form

This Agent of Record Form can be used to document assistance of an Exchange or Arkansas Works enrollment. In cases where Arkansas Blue Cross and Blue Shield does not receive an agent's NPN from the FFM (Federally Facilitated Marketplace) or Department of Human Services this form can be submitted to facilitate appropriate credit.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
My signature below is representative of my consent to provide information to below-named agent in order assist in the quoting and (potentially) enrollment process. Additionally, agent has provided me with instructions as to where and how I can access the privacy notice statement. | understand that this authorization can be used, should I end up enrolling with Arkansas Blue Cross and Blue Shield, as consent for agent to access certain information on my account. Further, it is my right to remove this authorization at any
Applicant Signature*

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Date*

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Date
Agent NPN: 6624853

Agent Phone Number: 888-608-1541

Agent Email Address: eatonagencyllc@gmail.com

I attest that I assisted the above client with their enrollment on the FFM or Insure Ark website.

Agent Name (print): Patrick Eaton
Date

MonthDayYear
Date
This form should not be used as a substitute for providing your NPN on the e-enrollment. If, after submitting an enrollment, you have found that you did not receive attribution as the Agent of Record for an enrollment you assisted, this can be used as supporting documentation for attribution. Please send to agentmarketingsupport@arkbluecross.com via secure/encrypted email for consideration. Arkansas BlueCross BlueShield
An Independent Licensee of the Blue Cross and Blue Shield Association
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Social Security Number*
Social Security Number*
Should be Empty: