Info.nystateofhealth.ny.gov
Broker of Record Template{Printed on employer group letterhead}NY State of HealthNew York State Department of HealthCorning Tower, Room 2580Albany, NY 12237Effective [date], [Employer Group Name] hereby designates [agent or agency] located at [business address] as our Broker of Record for group health and dental plans offered in the NY State of Health Small Business Marketplace.This designation of Broker of Record will remain in effect until we notify the Small Business Marketplace in writing to the contrary. This designation revokes any previous designation of a Broker of Record with the NY State of Health Small Business Marketplace._________________________________________ ______________________________Signature of Authorized Employer Representative Printed Name & Title_______________Date ................
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