The purpose of the Agent of Record (AOR) Designation Form is to provide notice to a participating insurance company of a MNsure member's/applicant's interest in designating an agent as that member's/applicant's "agent of record." It is understood that under this designation:
  1. The agent identified must have a license in good standing with the state of Minnesota, and has completed all requirements to be a certified agent with MNsure.
  2. The agent has an active appointment with the insurance company that issued the insured's policy.
  3. The appointed agent will be authorized on the date of signature below, to carrier information about the insured and the policy.
Agent Information

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* 1. Agent Full Name (First Last)

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* 2. Agency

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* 3. Agent National Producer #

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* 4. Agent Street Address (123 Example Street)

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* 5. Agent City

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* 7. Agent Zip Code (99999)

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* 8. Agent Phone Number (no dashes: format as 9999999999)

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* 9. Agent Email Address

AOR Designation Type

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* 10. Please indicate below the reason this form is being submitted.

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