Sales Submission Form
By completing this form you help ensure accurate commission tracking. This allows us to better support you through future remarketing, cross-selling, and retaining your clients. It will also post your sale on our DFG Discord Sales Channel!
Agent First Name
*
Agent Last Name
*
NPN#
*
Agent Email
*
Your insuredbydiamond.com email
Client First Name
*
PLEASE USE PROPER PUNCTUATION
Client Last Name
*
PLEASE USE PROPER PUNCTUATION
Client State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Client Phone Number
*
NUMBER ONLY NO DASHES
Client Email
Date of Birth
*
/
Month
/
Day
Year
Is this a Medicare Advantage client?
*
Yes
No
Medicare Number
NUMBER ONLY NO DASHES
Medicaid Number
LEAVE BLANK IF NOT ON MEDICAID
Medicaid Level
Please Select
QMB
QMB+
SLMB
SLMB+
QI
QDWI
FBDE
LEAVE BLANK IF NOT ON MEDICAID
SEP Code
Please Select
AEP
OEP
5-STAR
CHURN
Contract Violation
C-SNP
DST/FEMA
IEP
Institutional
LIS - LOSS OF STATUS
LIS - NEWLY OBTAINED
LIS/DUAL
LOSS OF COVERAGE
MOVE
Non-Renewal or Plan Termination
OCC
Retroactive Medicaid/LIS
SNP - LOSS
SPAP
Special Circumstances
Trial Right SEP
VA/TRICARE/FEHB Loss
Released from Incarceration
Plan ID
EXAMPLE: H1019-103-01
Have you completed the HRA?
*
Yes
No
No HRA Available
Plan Effective Date
*
/
Month
/
Day
Year
Date
Policy 1: Carrier
*
Please Select
Aetna
AIG
Allstate
Ambetter
American Amicable
Ameritas
ANICO
Anthem
AuguStar
Banner Health
Baylor Scott & White
BCBS Arizona
BCBS Michigan
Blue Cross Blue Shield
Caresource
Cigna
Clover Health
Corebridge Financial
Devoted
Enroll Prime
Equitable
Essence Health
F&G
Foresters
Foresters Financial
Freedom/Optimum
Global Atlantic
GTL
Humana
Imperial
Iron Health
John Hancock
Kelsey-Seybold
Legal & General
LifeX
Lincoln Financial
Manhattan Life
MassMutual
Medical Mutual
Medigold
Molina
Mutual of Omaha
National Life Group
NCD
Nationwide
New York Life
North American
Oscar
OneAmerica
Optimum
Other
Pivot Health
Principal
Priority Health
Protective Life
Prudential
SCAN
Securian Financial
Security Mutual Life
Select Health
Solis Health
Symetra
Transamerica
UHC
UHONE
UCLA Health
United Home Life
UPMC
Wellcare
Zing Health
Policy 1: Product
*
Please Select
ACA
Accident Medical Expense
Annuity
Critical Illness
Dental
Dental/Vision
Dental/Vision/Hearing
Final Expense
Group Medical
Hospital Indemnity
Health Insurance
Home Healthcare
IUL
Major Medical
MAPD
MA Only
Medicare Supplement
Medicare Supplement Plan G
Medicare Supplement Plan N
Private Health Insurance
Short Term Medical
Term Life Insurance
Whole Life Insurance
Policy 1: Annual Premium
*
USE 3000 FOR MAPD PLANS
Policy 2: Carrier
Please Select
Aetna
AIG
Allstate
Ambetter
American Amicable
Ameritas
ANICO
Anthem
AuguStar
Banner Health
Baylor Scott & White
BCBS Arizona
BCBS Michigan
Blue Cross Blue Shield
Caresource
Cigna
Clover Health
Corebridge Financial
Devoted
Enroll Prime
Equitable
Essence Health
F&G
Foresters
Foresters Financial
Freedom/Optimum
Global Atlantic
GTL
Humana
Imperial
Iron Health
John Hancock
Kelsey-Seybold
Legal & General
LifeX
Lincoln Financial
Manhattan Life
MassMutual
Medical Mutual
Medigold
Molina
Mutual of Omaha
National Life Group
NCD
Nationwide
New York Life
North American
Oscar
OneAmerica
Optimum
Other
Pivot Health
Principal
Priority Health
Protective Life
Prudential
SCAN
Securian Financial
Security Mutual Life
Select Health
Solis Health
Symetra
Transamerica
UHC
UHONE
UCLA Health
United Home Life
UPMC
Wellcare
Zing Health
LEAVE BLANK IF ONE POLICY ONLY
Policy 2: Product
Please Select
ACA
Accident Medical Expense
Annuity
Critical Illness
Dental
Dental/Vision
Dental/Vision/Hearing
Final Expense
Group Medical
Hospital Indemnity
Health Insurance
Home Healthcare
IUL
Major Medical
MAPD
MA Only
Medicare Supplement
Medicare Supplement Plan G
Medicare Supplement Plan N
Private Health Insurance
Short Term Medical
Term Life Insurance
Whole Life Insurance
LEAVE BLANK IF ONE POLICY ONLY
Policy 2: Annual Premium
LEAVE BLANK IF ONE POLICY ONLY
Policy 3: Carrier
Please Select
Aetna
AIG
Allstate
Ambetter
American Amicable
Ameritas
ANICO
Anthem
AuguStar
Banner Health
Baylor Scott & White
BCBS Arizona
BCBS Michigan
Blue Cross Blue Shield
Caresource
Cigna
Clover Health
Corebridge Financial
Devoted
Enroll Prime
Equitable
Essence Health
F&G
Foresters
Foresters Financial
Freedom/Optimum
Global Atlantic
GTL
Humana
Imperial
Iron Health
John Hancock
Kelsey-Seybold
Legal & General
LifeX
Lincoln Financial
Manhattan Life
MassMutual
Medical Mutual
Medigold
Molina
Mutual of Omaha
National Life Group
NCD
Nationwide
New York Life
North American
Oscar
OneAmerica
Optimum
Other
Pivot Health
Principal
Priority Health
Protective Life
Prudential
SCAN
Securian Financial
Security Mutual Life
Select Health
Solis Health
Symetra
Transamerica
UHC
UHONE
UCLA Health
United Home Life
UPMC
Wellcare
Zing Health
Policy 3: Product
Please Select
ACA
Accident Medical Expense
Annuity
Critical Illness
Dental
Dental/Vision
Dental/Vision/Hearing
Final Expense
Group Medical
Hospital Indemnity
Health Insurance
Home Healthcare
IUL
Major Medical
MAPD
MA Only
Medicare Supplement
Medicare Supplement Plan G
Medicare Supplement Plan N
Private Health Insurance
Short Term Medical
Term Life Insurance
Whole Life Insurance
Policy 3: Annual Premium
Submit Your Sale
Should be Empty: