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AOR Change Request/Pay Audit Request Form
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Date of Request
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Agent Information: (one AOR per request)
For Agents Who are Paid Direct: Send to AgentSupport@humana.com
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Agent NameByron Edwards
For Partner-Level Commission issues: Send to Account Executive
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Agent SAN19742285
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Partner Information:
**All information below is required for audit purposes.
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Partner Name
Please use the Instructions tab for further details on the fields required.**
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Partner SAN
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Contact Information:
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Agent/Partner Phone#
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Agent/Partner E-Mail
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Group Number
Product Type
Contract/ PBPEffective DateCurrent Writing Agent SANREQUESTED writing agentIssue CategoryAOR SAN (commissions assigned) Member
First Name 		Member
Last Name 		UMIDMedicare Number or
SSN (no dashes or spaces)		Additional CommentsHumana Comments (OFFICE USE ONLY)
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