INSURANCE PRODUCER FEE DISCLOSURE FOR THE SALE OF AN INDIVIDUAL HEALTH BENEFIT PLAN


I, Barbara Gordon, hereby disclose to on  that I MAY NOT receive any compensation for the individual health benefit plan you have selected.

Subject to the penalties set forth in § 10-2-801, C.R.S., I certify, through this notice, that IF I DO NOT RECEIVE COMMISSION for the sale of the individual health benefit plan from the carrier offering the individual health benefit plan, I will charge you the price below. I also certify that I will charge the same fee for the sale of an on-exchange individual health benefit plan as an off-exchange individual health benefit plan.

If I am paid commission for the sale of this individual health benefit plan in the future, I agree to refund the full amount of the fee that you have paid.

I will not charge a fee for assisting in enrollment in Medicaid or the Children’s Basic Health Plan.

The fee that I will charge you for the sale of an individual health benefit plan will be: $250.

 

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Signed by Barbara Gordon
Signed On: October 4, 2018

A+ Smart Health Insurance Agency https://www.smartsummithealth.com
Signature Certificate
Document name: INSURANCE PRODUCER FEE DISCLOSURE FOR THE SALE OF AN INDIVIDUAL HEALTH BENEFIT PLAN
Unique Document ID: 64568d8844437227fb34552a1ee57c2772394978
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September 13, 2018 11:00 am MDTINSURANCE PRODUCER FEE DISCLOSURE FOR THE SALE OF AN INDIVIDUAL HEALTH BENEFIT PLAN Uploaded by Barbara Gordon - barb@smartsummithealth.com IP 76.120.78.53