Agent of Record Letter for Lisa Chamberlain
Important Terms & Conditions, Please Read Carefully:
I hereby designate Lisa Chamberlain as Agent of Record, effective as of the date of signature with respect to the medical and/or dental insurance product(s) purchased from carrier.
In making this designation, I authorize my Agent of Record to access information about my insurance products and represent me to facilitate the ongoing service of my products.
I understand that adding or changing the Agent of Record does not change the premium of my product(s) and is included as part of my policy at no additional cost. Any compensation payable to an agent should be directed to:
Utah Avenue Insurance
910 E 100 N, Ste 105
Payson, UT 84651
This Agent of Record Letter rescinds any prior appointments of agent/agency with respect to this coverage and shall remain in effect until revoked or replaced in writing.
I understand that the terms and conditions of this appointment will be subject to carrier’s specific contractual requirements, as well as your normal agent appointment procedures.
I understand that carrier may contact me to validate the authenticity of this letter. I have provided my phone number and email.
The Agent of Record shown above hereby accept the designation set forth above and confirms the representations made herein.