Enrollment Inquiry Form
Complete the form below to request assistance from GarityAdvantage on a specific enrollment. "Inquiry Type" choice will open different fields required so our enrollment team can investigate your inquiry.
Submitted by
*
Agent Name
*
First Name
Last Name
Agent Email
*
example@example.com
Inquiry Type
*
Status
Election
Status Inquiry Details
Carrier Name
*
Plan Type
*
Client Name
*
First Name
Last Name
Client Medicare #
*
Client Date of Birth
*
-
Month
-
Day
Year
Date
Date of Submission
*
-
Month
-
Day
Year
Date
Submission Method
*
Fax
Email
Agent Dashboard
Other
Election Inquiry Details
Client Date of Birth
*
-
Month
-
Day
Year
Date
Client Medicare Part A Effective Date
*
-
Month
-
Day
Year
Date
Client Medicare Part B Effective Date
*
-
Month
-
Day
Year
Date
Brief explanation of client's circumstances
*
Other Enrollment Related inquiry/notes/details
Submit
Should be Empty: