PIP Interest Form

Complete the form to have a representive from PIP contact you. This service is a partnership through GarityAdvantage Agencies.

Qualified* Agents NEW to MedicareEXPRESS are eligible for 10% off orders.

Who is completing form?*

Garity Staff Name*

First NameLast Name

Agent Name*

First NameLast Name

Agent Email*

example@example.com

Agent Phone Number*

Area CodePhone Number

Agent NPN*

Agent Resident State*

Agent Comments/Questions

*Agent must have 3+ Active MAPD Contracts with GarityAdvantage to qualify for the PIP special offer. Need contracts? Get started here: garityadvantage.com/getcontracted

Or Call/Email us to discuss your options:
800-234-9488 / recruitment@garityadvantage.com

By completing this form and providing your name, email, postal or residential address, and/or phone number, you hereby expressly consent to receive electronic and other communications from GarityAdvantage Agencies, over the short term and periodically, including email and text communications. These communications will be about their services, new product offers, promotions, and other matters. You may opt out of receiving electronic communications at any time by following the unsubscribe instructions contained in each communication, or by sending an email to marketing@garityadvantage.net. You agree that these electronic communications satisfy any legal requirements that communications or notices to you be in writing.

For Garity Use Only

Marketing Check: Is agent Active and Qualified for Partner Special Offer?

YESNO

Director