Blue Cross Blue Shield of Minnesota Agent of Record/Plan Change Form
Name:
Phone:
Address:
City:
State:
Zip:
E-mail:


Steven A. Ehlen, Agent #HFBE6161
MN Insurance license #200889301

Holland & Frank Executive and
Employee Benefit Solutions, Inc
Independent Agent for Blue Cross Blue Shield of Minnesota
1101 2nd St. S. Suite 110
Sartell, MN 56377

 Office:       (320) 252-2799
Toll-free:   (888) 577-1142
Fax:            (320) 257-4584
                   (877) 577-5437

E-mail: steve@hollandandfrank.com
On the top of the Opions Blue Change Form fill in you name and contract ID number. Proceed to section G and select deductible option with 100% or 80% coverage and preventative benefit option. Sign and date the form.

Click continue for Plan Change.
You will need to fill in the Agent of Record Assignment form with Name and ID number. Sign and date. Both forms will need to be sent to my address: 1101 2nd Street South Suite 110, Sartell, MN 56377. If you have any questions, do not hesitate to contact me, Steven A Ehlen, directly at 888-577-1142.