Marketplace Representation Authorization
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.
Lion's Pride Insurance
Agent NPN: 17957987
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.
Lion's Pride Insurance
851 North 100 East,
Spanish Fork, UT 84660
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.
I hereby authorize The Chesapeake Life Insurance Company ("the Company") to charge the credit card or debit card account identified below (the "Account") for up to the amount specified below and to receive payment of such amount from the Account in payment of the premium with respect to the insurance policy applied for by me or by the primary applicant identified below (the "Coverage"). I understand and agree that, if any charge authorized hereby is denied, the Company will contact me to make arrangements for an alternate form of payment, and that, if I provide, verbally or in writing, corrected information for the Account or information for another credit card or debit card account (an "Alternate Account") to the Company, this Authorization includes full authority for the Company to charge the Account using such corrected information or charge any Alternate Account for the amount and purpose specified herein.
I understand and agree that (i) the Coverage, or any portion thereof as applicable, will not be issued and will not become effective unless and until payment of the full amount of premium shall have been received by the Company; (ii) any charge made pursuant to this Authorization will be made for payment of premium only; (iii) reversal or contest of, or objection to, any charge made pursuant to this Authorization shall constitute failure to pay premium in full which will automatically render the Coverage, or any portion thereof as applicable, rescinded, void and unenforceable on and as of the date of issuance and will release and exonerate the Company from any and all liability under the Coverage, or any portion thereof as applicable, including without limitation liability for payment of any and all claims for benefits submitted thereunder; and (iv) the issuer of any credit card or debit card to be charged pursuant to this Authorization is not acting and will not act as an agent of either the Company or me in accepting and paying the charge authorized hereby.
I understand the premium will be charged to the Card upon receipt of this authorization. I understand that I have the right to receive a refund of policy premium if I cancel the policy and provide written notice to The Chesapeake Life Insurance Company, at 100 Centerville Dr., Suite 100, Nashville, TN 37214, in accordance with the terms and conditions of the insurance policy.