Do you need to make a change to your group or individual’s Broker of Record (BOR), GA of Record or TPA of Record status? Follow the steps below to help guide you through the process.

Group BOR Change:

1. Download the BOR Authorization Form.

2. Fill out all Broker, GA and TPA-related fields, as applicable, then sign the Broker Contact Information section.

3. Send to your group to fill in and sign the Employer Group Contact Information section.

4. When the group sends the completed form back to you, take the following action:

• If it is a Broker of Record change only: You can email the form directly to Kaiser Permanente’s Broker Shared Services Center at brokersupport-mas@kp.org.
• If the change request also includes a GA or TPA change: Send the completed form to your GA partner. GA/TPA partners will be responsible for submitting completed forms to Kaiser Permanente’s Broker Shared Services Center at brokersupport-mas@kp.org when a GA and/or TPA change is being requested.

Individual BOR Change:

1. Ask your client to fill out and sign the Agent of Record Authorization Form.

2. Submit the form via email to Kaiser Permanente’s Broker Shared Services Center at brokersupport-mas@kp.org.

When the BOR change is complete, you will receive either a win or loss letter notifying you of the change effective date.

Additional Policy and Process Notes:

• Effective date policy: The effective date for Broker, GA and TPA of Record requests will be the first day of the month following 30 days of the receipt of a completed change request by the Broker Shared Services Center.
• Only fully appointed Kaiser Permanente brokers are entitled to receive commissions in conjunction with the placement, installation and/or servicing of our insurance contract/agreement.
• If a group has any past due balances, requests to change the TPA of record will not be approved until the group is current on their payments.

If you have any questions about this process, please contact your Sales or Account Management representative.