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: May 29, 2019

Boone Insurance Associates https://booneinsuranceassociates.com
Signature Certificate
Document name: Agent of Record Authorization Form
Unique Document ID: 3f996800294033ffcd8880906e6fcadd15bfb8f0
Timestamp Audit
May 20, 2019 10:19 am PDTAgent of Record Authorization Form Uploaded by Christopher Boone - [email protected] IP 199.66.198.50