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Agent of Record Authorization Form

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

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

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