Marketplace Representation Authorization for Lisa Chamberlain

Assistance with completing your marketplace application

For certified application counselors, navigators, agents, and brokers only

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling the application for somebody else.

Agent: Lisa Chamberlain
Utah Avenue Insurance
Agent NPN: 16670644

You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change or remove your authorized representative, contact the Marketplace. If you’re a legally appointed representative for someone on their application, submit proof with the application.
Authorized Representative:

Lisa Chamberlain
Utah Avenue Insurance
910 E 100 N, Ste 105
Payson UT 84651
801.609.8699

By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters related to this application.