Inquiry Request
Agent Name
First Name
Last Name
Agent Email
example@example.com
Add'l Email to be Cc'd on Response
example@example.com
Agent Phone Number
Please enter a valid phone number.
Type of Inquiry
*
Commission Inquiry
Contracting Inquiry
General Inquiry
Commissions Inquiry
How many policies would you like to inquire on?
One
Multiple
Single Policy Inquiry - Allow up to 48 hrs for response
Carrier
Please Select
Aetna/Silverscript
Aetna Senior Supplement
Ameritas
Anthem
Anthem Empire
BCBS (IL)
BCBS (RI)
BCBS (TN)
Capital Blue
CareFirst - Med Adv
Care First - Med Supp
Cigna Healthspring
Commonwealth Care Alliance
Connecticare
Emblem
eternalHealth
Fallon Health
Gateway
Geisinger
Gerber Life
Guarantee Trust Life
Harvard Pilgrim - Med Adv
Harvard Pilgrim - Med Supp
Health New England
Highmark
Humana
Kaiser Permanente
Mass Advantage - Central Mass Health
Molina
Mutual of Omaha
Premier Senior Health
Tufts
United American
UnitedHealthcare® Medicare Solutions
WellCare
Writing ID / NPN
Client Name
First Name
Last Name
Client Date of Birth
-
Month
-
Day
Year
Date
Medicare Beneficiary ID
Policy Number
Plan Type
Policy Effective Date
-
Month
-
Day
Year
Date
Application Date
-
Month
-
Day
Year
Date
Issue (Missing renewal, True-Up, etc.) & Dates Missing
Form Completed By
First Name
Last Name
Multiple Policy Inquiry - Allow up to 48 hrs for response
To inquire on multiple policies, download the
template
and upload completed sheet.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Contracting Inquiry
Support Type
Please Select
Assistance Completing Contract
Resend Contract
Certifications
Close Contract Request
Contract Status Inquiry
Other
Carrier(s)
Brief Explanation of Inquiry
File Upload (if applicable)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
General Inquiry
Please describe your inquiry
File Upload (if applicable)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Form Completed by
First Name
Last Name
Submit
Should be Empty: