Agent of Record Authorization Form

I,  , authorize Boone Insurance Associates, Inc. (BIA) to take the following actions on my behalf & represent my interests:

  1. To assist me with my eligibility determination, enrollment and service matters including but not limited to: claims, benefits and premiums.
  2. To access my Personally Identifiable Information (PII) for the purpose of assisting with enrollment and servicing my account; and
  3. To be listed as my servicing agency.


I have read and understand the nature of this Authorization.  By signing below I am granting the authorization and it is my desire to grant BIA the authority to enroll me in a plan.


Agency: Boone Insurance Associates

Managing Agent: Chris Boone                                             

Managing Agent NPN:8008427

Leave this empty:

Signed by Christopher Boone
Signed On: January 6, 2020

Boone Insurance Associates
Signature Certificate
Document name: Agent of Record Authorization Form
Unique Document ID: 0778f09f187f7f76a867342f3d1f5e6edd7c9560
Timestamp Audit
May 20, 2019 10:19 am PDTAgent of Record Authorization Form Uploaded by Christopher Boone - [email protected] IP 2601:1c0:ce02:2df0:a4be:dfdf:e0f9:8a35