[Date]

Commissions Department 

Individual and Small Employer Division

Blue Cross and Blue Shield of New Jersey

3 Penn Plaza East, MS PP  9Q

Newark, NJ  07105-2200

RE:    [Group Name]

Group #      -                                                                             

This will notify you that our company has appointed Brokerage Concepts, Inc. through John J. Slattery Associates, Inc whose business address is 1800 Route 34, Building 1, Suite 102 Wall, NJ 07719, as Broker of Record for our Horizon Blue Cross and Blue Shield of N.J. health coverage effective immediately.  I further understand that Brokerage Concepts, Inc. is not an employee of Horizon Blue Cross and Blue Shield of New Jersey.

Commissions should be paid to our company’s Broker-of-Record as of the effective date stated in this letter.  This designation of our Broker-of-Record will remain in effect until we notify you in writing to the contrary.  This replaces any previously appointed broker.

We understand that as of the above effective date, our new broker-of-record will receive commission payment for our account, and our previous broker-of-record will cease to receive commission payment on our account. 

Further, we agree that any such notice shall apply prospectively to future contract renewals. 

Sincerely,

_______________________________

Signature of Company Official

_______________________________

Name of Company Official  

_______________________________

Title of Company Official