Authorization for Electronic Plan Submission

I, , authorize Boone Insurance Associates, Inc. (“BIA”) to take the following actions on my behalf & be agent of record on my account: 1) To assist me with my Federally-facilitated Exchange (“Marketplace”) eligibility determination in a Qualified Health Plan (“QHP”), including any electronic communications with QHP providers; 2) To access my Personally Identifiable Information (“PII”) for the purpose of assisting with the Marketplace eligibility determination and/or QHP enrollment; and 3) To be listed as the agent of record on my account under Chris Boone NPN#8008427 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 the authority to enroll me in a plan.

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Signed by Christopher Boone
Signed On: September 18, 2018

Boone Insurance Associates
Signature Certificate
Document name: Authorization for Electronic Plan Submission
Unique Document ID: be1d9996adf5931fd11ed1a1913728293704a5d9
Timestamp Audit
September 14, 2018 2:46 pm PDTAuthorization for Electronic Plan Submission Uploaded by Christopher Boone - [email protected] IP