WP E-Signature by Approve Me - Sign Documents Using WordPress -

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:

To assist with my Federally facilitated Exchange (“Marketplace”) account and use my information to review and/or update the account; including but not limited to enrollment in a Qualified Health Plan (“QHP”)
To assist with eligibility determination in a Qualified Health Plan (“QHP”), including assisting with any electronic communications with QHP providers, assisting with applying for advance payments of the premium tax credit and cost-sharing reductions, and conducting searches for current applications on approved Classic Direct Enrollment or Enhanced Direct Enrollment websites.
To access my Personally Identifiable Information (“PII”) for the purpose of assisting with the Marketplace eligibility determination and/or QHP enrollment; and
To be listed as the agent of record on my account.

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/

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signed by Christopher Boone
Signed On: September 19, 2023

Timestamp

Audit

November 12, 2018 5:21 pm PDT

Authorization for Electronic Assistance - IFP Uploaded by Christopher Boone - [email protected] IP 173.11.29.21

November 12, 2018 5:37 pm PDT