Employer Representative Authorization

Required documentation must be submitted to Blue Cross and Blue Shield of Texas (BCBSTX) by an employer group to apply for group health and/or dental benefit plans. BCBSTX requires that an employee or owner of the employer applying for benefits sign the application for coverage and other applicable documentation. In the event that the person signing on behalf of the employer is not an employee or owner of the employer, BCBSTX will accept this form as evidence that the employer has designated the individual set forth herein as its representative with full power and authority to bind the employer.

Name of individual authorized by the employer to execute/receive documents on employer’s behalf, as noted below April Peters (Please print)

Check applicable boxes below to indicate documents that above named individual is authorized to execute/receive on behalf of employer:

1. Employer’s application for coverage

2. Employer’s Billing and Correspondence

3. Employer requests BCBSTX send all premium bills under Employer’s Policy to the address of the above named individual. These bills should be addressed to: 2600 SW Freeway, Suite 1001, Houston, TX 77098

Employer acknowledges and agrees that Employer remains fully responsible for timely payment of premium to BCBSTX. Specifically, Employer acknowledges that if their designee does not remit billed premium to BCBSTX in full by the end of the Grace Period specified in the Employer’s Policy with BCBSTX, BCBSTX may terminate the Policy as provided in the Policy or take any other action permitted under the Policy.

Employer shall notify BCBSTX in a timely manner should they desire to revise any of the information provided on this form.

Employer (Legal Name of Company)

_______________________________________

Employee/Owner of Company (Please print)

_______________________________________

Employee/Owner of Company (Signature)

Title

Date

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association