Agent of Record Authorization Form
I, , authorize Boone Insurance Associates, Inc. (BIA) to take the following actions on my behalf & represent my interests:
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: May 29, 2019
If you have questions about the contents of this document, you can email the document owner.
Document Name: Agent of Record Authorization Form
Agree & Sign