Agents Brokers Revoke Form – 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: XX/XX/20XX

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.

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: 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, expiration date is XX/XX/20XX. The time required to complete this information collection is estimated to take up to 0.17 hours per applicant per year, including the time to review instructions, gather the information needed, and complete and review the information collection. 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, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. CMS Disclosure Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Brian Gubin at Brian.Gubin@cms.hhs.gov