Authorization for Electronic Assistance - Major Medical
Boone Insurance Associates, Inc.
Authorization for Electronic Assistance – Major Medical
I, , authorize Boone Insurance Associates, Inc. (“BIA”) to take the following actions on my behalf & be agent of record on my behalf:
All actions by BIA shall be in accordance with 45 CFR 155.220, and the terms of the Agent Broker General Agreement for the Federally-Facilitated-Facilitated Exchange Individual Market (“General Agreement”) and the Agreement Between Agent Or Broker And the Centers For Medicare and Medicaid Services for the Federally-Facilitated Exchange Individual Market (“IM Agreement”).
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 By signing below I am granting the authorization and it is my desire to grant BIA this authority which can be rescinded by me at any point.
Agency: Boone Insurance Associates
Managing Agent: Chris Boone
Managing Agent NPN: 8008427
Leave this empty:
Signed by Christopher Boone
Signed On: September 25, 2019
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization for Electronic Assistance - Major Medical
Agree & Sign