TO: Blue Cross of California

Small Group Services

P. O. Box 9062

Oxnard, CA. 95031-9062

RE:

POLICY#:___________________________________________________________

INSURED:___________________________________________________________

ADDRESS:___________________________________________________________

Please be advised that I wish to appoint RICHARD W. SUESS AGT# 62299 as

the broker of record for the above referenced policy, to become effective__________.

Thank you!

NAME:____________________________________

TITLE:____________________________________

DATE:____________________________________