This Molina Marketplace Agent of Record Form (“AOR Form”) shall be completed by a Molina Marketplace member or subscriber (“You” or “Your”) to designate an agent as the agent of record (“AOR”) associated with Your Molina Marketplace membership. An agent should only be designated as Your AOR if the agent substantially assisted You with Your Molina Marketplace coverage.
All verified AOR Forms received prior to the 15th of each month will be in effect the first day of the following month. Verified AOR Forms received on or after the 15th of the month will be effective the first day of the second following month.
Subscriber (Primary Applicant) Name: [ name will be inserted from field below ] Subscriber ID, Exchange ID or Member ID: [ information will be inserted from fiel below ] Subscriber State: Utah
New Agent of Record Information Please provide the following information for the agent that You wish to designate as Your AOR: Agent Name: Lloyd Coleman Agent Phone Number: 801-432-5012 Agent E-mail Address: lloyd@clarityinsurance.com National Producer Number: 5460834 Agent Tax ID Number and/or License Number (California and Washington only): N/A
Member Attestation I attest that the above-named agent provided substantial assistance with my enrollment or membership in Molina Marketplace. I understand that by submitting this AOR Form that any prior AOR designation with respect to my coverage will be rescinded, and that the designation of the above-named agent as my AOR will remain in effect until revoked or replaced in writing.
By clicking submit, you are signing electronically.