NEW Inquiry Request

Agent Inquiry Request
Agent Name

First NameLast 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.Format: (000) 000-0000.
Type of Inquiry
- How many policies would you like to inquire on?
- Carrier
- NPN
- Agent Carrier Writing ID
- Client Name
  
  First NameLast Name
- Client Date of Birth
  
  MonthDayYear
  Date
- Medicare Beneficiary ID
- Policy Number
- Plan Type
- Was this a traditional enrollment or an Agent of Record change?
- AOR Submission Date
  
  MonthDayYear
  Date
- Application Date
  
  MonthDayYear
  Date
- Policy Effective Date
  
  MonthDayYear
  Date
- Have you confirmed the policy is active with the carrier?
- Please confirm with the carrier the policy is active prior to submitting form.
- Issue (Missing renewal, True-Up, etc.) & Dates Missing
- To inquire on multiple policies, download the template and upload completed sheet.
- Cancelof
- Support Type
- Carrier(s)
- Brief Explanation of Inquiry
- File Upload (if applicable)
  
  Cancelof
- Please describe your inquiry
- File Upload (if applicable)
  
  Cancelof
- Please fill out the below if you would like to refer a new agent to the WeCanHelpYou Agent Network. Once the new agent is contracted, we will pay you $250!
- Name of New Agent Referred
  
  First NameLast Name
- Phone Number of New Agent Referred
  Please enter a valid phone number.Format: (000) 000-0000.
- Email Address of New Agent Referred (optional)
  example@example.com
- Type of Marketing Campaign
- Type of Marketing Effort
- Name of Vendor
- Description of Effort
- Date of Marketing Effort
  
  MonthDayYear
  FYI - There is 60 day deadline from the date of incurrence for co-op reimbursement requests.
- Total Investment
- Has this co-op been submitted to another marketer or carrier?
- If yes, to whom and how much?
- If you have not been paid a co-op or commissions from Hilb Group Medicare before, please complete and electronically sign the document at this link:
  
  Broker Payment Forms
- Upload Copy of Receipt and W9/EFT Form * Must be a PAID receipt, not an invoice
  
  Cancelof
- Is this part of a Fast Start Campaign?
- Fill out the fields below to request a .CSV file with your requested data.
  
  List will include prospect name, address, phone number and T65 month.
  
  Please only request lists that you plan on using within the next 30 days. Thank you!
- How will you be marketing to this list of prospects?
  
  Other
- Zip Codes (separate by comma)
- Would you like a pre or post-65 leads?
- T-65 - Which future months would you like to include?
- Income Range Parameters
- Language Parameters
- Preferred Username
- Do you currently use a CRM solution (Customer Relationship Management - Client Database)?
- Current CRM Solution Provider
  Name of current solution vendor
- Subscription Payment
  prevnext( X )
  AgencyBloc Subscription
  AgencyBloc CRM Subscription
  
  $75.00 for each month
- Please assist me in creating the following forms in my Jotform account:
- Do you currently have a Jotform account?
- Name of Client Being Referred
  
  First NameLast Name
- Phone Number of Client Being Referred
  Please enter a valid phone number.Format: (000) 000-0000.
- Email of Client Being Referred
  example@example.com
- Address of Client Being Referred
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Please give us any further information needed to service this client:
- This form is only to ensure we track your referral correctly and you receive your referral fee once the commission is received by the agency.
  
  Please have your client call our team at 855-479-4005 and follow the prompts for new clients or email clientservice@hilbmedicare.com.
- Our marketing partner, GarityAdvantage, is your resource to inquire on issues with MedicareCENTER enrollment software. Please submit the MedicareCENTER Support Request on the GarityAdvantage Agent Dashboard if you need assistance.
- Form Completed by
  
  First NameLast Name
- Should be Empty:

Agent Inquiry Request

Subscription Payment*

Subscription Payment