NYS of Health - Broker of Record

NYSoH Broker or Record Assignment Form

NY State of Health

New York State Department of Health

Corning Tower, Room 2580

Albany, NY 12237

Effective Today (enter today's date):

Name of Individual on the Insurance Plan:

NYSoH 10-digit Account Number (if available)

I hereby designate Thomas Bell, KBellbenefits, LLC, located at 15 Schoen Place, Pittsford, New York, as my Broker of Record for health and dental plans offered in the NY State of Health Individual Marketplace.

This designation of Broker of Record will remain in effect until I notify the Individual Marketplace in writing to the contrary. This designation revokes any previous designation of a Broker of Record with the NY State of Health Individual Marketplace.

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KBellbenefits, LLC, an associate of Pullano & Company,

15 Schoen Place, Pittsford, NY 14534