Agent Broker Revoke – Hall Biddle & Associates, Inc.

Agent Broker Revoke Form

Hall Biddle and Associates, Inc

Marketplace Agents and Brokers Revoke Form

OMB Control Number: 0938-1438 Expiration Date: 07/31/2028

I, the undersigned applicant, hereby Revoke my permission to Hall Biddle and Associates, Inc, to serve as the health insurance agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace and/or State Base.

Name of Primary Writing Agent:(Required)

Agent National Producer Number(last 4 digits)(Required)

Agent Email Address(Required)

Agent Phone Number(Required)

Agency Name:(Required)

Agency National Producer Number(last 4 digits)(Required)

Owner of Agency(Required)

Agency Phone Number:(Required)

Agency Email Address(Required)

Name of Applicant and/or Authorized Representative:(Required)

Applicant's Phone Number(Required)

Applicant's Email Address(Required)

Applicant's Signature(Required)

Applicant's Signature Date(Required)
MM slash DD slash YYYY

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938 1438. This information collection specifically details what information will be required to be collected and maintained by agents, brokers, and web-brokers were they to receive a request from HHS for consent records. This information collection will provide HHS with documentation that may be used for monitoring, audit, and enforcement activities. The time required to complete this information collection is estimated to take up to 10 minutes per applicant per year, which includes the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is pursuant to 45 C.F.R. §155.220(c)(5), which states that HHS or its designee may periodically monitor and audit an agent, broker, or web-broker under this subpart to assess its compliance with the applicable requirements of this section. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850, Attention: Information Collections Clearance Officer or email Brian Gubin at Brian.Gubin@cms.hhs.gov.