Assignment of Personal Representative Form

Purpose of the form and directions for completing the form.

This form should be completed and sent to the Health Reinsurance Association (HRA) only if you would like to have someone other than you to be able to call HRA and receive information about your account. You must complete the form with the name, address, relationship and other information about this person or persons so HRA can properly identify callers that you wish to have access to your personal information.

You do not need to complete this form if you do not want anyone other than yourself to have access to your information.

You do not need to assign yourself as your own personal representative.

Personal Representative Form (pdf)

Note: To view the form you must have AdobeĀ® ReaderĀ®.

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