Authorization for Electronic Assistance - IFP
Boone Insurance Associates, Inc.
Authorization for Electronic Assistance
I, , authorize Boone Insurance Associates, Inc. (“BIA”) to take the following actions 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 which will be valid until revoked by me at any time by providing written notice of the revocation to BIA.
I confirm that the information in my application is accurate.
I have reviewed and I understand the attestations at the end of my eligibility application*.
I acknowledge BIA has informed me of BIA’s functions and responsibilities as an agent/broker in the Marketplace.
By signing below, I am granting BIA authorization as stated above.
Agency: Boone Insurance Associates
Managing Agent: Chris Boone
Managing Agent NPN: 8008427
*Additional information on the agreement statements in the eligibility application are available upon request, or visit: https://www.healthcare.gov/help/agreement-statements/
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Your legal name
Your email address
Signed by Christopher Boone
Signed On: September 19, 2023
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization for Electronic Assistance - IFP
Agree & Sign