DFG Sales Submission Form

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*
Client Phone Number*
NUMBER ONLY NO DASHES
Client Email
Date of Birth*

MonthDayYear
Is this a Medicare Advantage client?*

YesNo
Medicare Number
NUMBER ONLY NO DASHES
Medicaid Number
LEAVE BLANK IF NOT ON MEDICAID
Medicaid Level
LEAVE BLANK IF NOT ON MEDICAID
SEP Code
Plan ID
EXAMPLE: H1019-103-01
Have you completed the HRA?*

YesNoNo HRA Available
Plan Effective Date*

MonthDayYear
Date
Policy 1: Carrier*
Policy 1: Product*
Policy 1: Annual Premium*
USE 3000 FOR MAPD PLANS
Policy 2: Carrier
LEAVE BLANK IF ONE POLICY ONLY
Policy 2: Product
LEAVE BLANK IF ONE POLICY ONLY
Policy 2: Annual Premium
LEAVE BLANK IF ONE POLICY ONLY
Policy 3: Carrier
Policy 3: Product
Policy 3: Annual Premium
Should be Empty: