(To be place on your company letterhead )

___/___/____

Commissions Department
Individual and Small Employer Division 
Horizon Blue Cross and Blue Shield of New Jersey, Inc. 
3 Penn Plaza, PP-10A 
Newark, New Jersey 07105-2200 
Group #: 
To whom it may concern: 
                        This will notify that our company has appointed Philip Wallace Lowcher Inc., of Emerson Reid & Co. #011749 as the Broker of Record for our Horizon Blue Cross Blue Shield of New Jersey coverage, effective ___/___/___.   I further understand that Philip Wallace Lowcher Inc. is not an employee of Horizon Blue Cross and Blue Shield of New Jersey, or HMO Blue.
Commissions should be paid to our company's new Broker-Of-Record, Philip Wallace Lowcher Inc. 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, 
_x_______________________

______________________________
Printed Name, Group Correspondent