Prospect List Request Form

Prospect List Request Form
Please be advised that you cannot “cold call” for Medicare Advantage Plans, it is a violation of CMS Guidelines. These lists are only for Medicare Supplement Plans.
Name*

First NameLast Name
Cellular Number*
E-mail*
example@example.com
I intend to:*

CallMailBoth
What type of Lists
List count requested:*

255075100+
State:*
What county or counties would you like to focus on?*
Chose the CT county or counties you will focus on:*

Fairfield CountyHartford CountyLitchfield CountyMiddlesex CountyNew Haven CountyNew London CountyTolland CountyWindham County
Chose the MA county or counties you will focus on:*

Barnstable CountyBerkshire CountyBristol CountyDukes CountyEssex CountyFranklin CountyHampden CountyHampshire CountyMiddlesex CountyNantucket CountyNorfolk CountyPlymouth CountySuffolk CountyWorcester County
Chose the ME county or counties you will focus on:*

Androscoggin CountyAroostook CountyCumberland CountyFranklin CountyHancock CountyKennebec CountyKnox CountyLincoln CountyOxford CountyPenobscot CountyPiscataquis CountySagadahoc CountySomerset CountyWaldo CountyWashington CountyYork County
Chose the NH county or counties you will focus on:*

Belknap CountyCarroll CountyCheshire CountyCoos CountyGrafton CountyHillsborough CountyMerrimack CountyRockingham CountyStrafford CountySullivan County
Chose the NY county or counties you will focus on:*

Albany CountyAllegany CountyBronx CountyBroome CountyCattaraugus CountyCayuga CountyChautauqua CountyChemung CountyChenango CountyClinton CountyColumbia CountyCortland CountyDelaware CountyDutchess CountyErie CountyEssex CountyFranklin CountyFulton CountyGenesee CountyGreene CountyHamilton CountyHerkimer CountyJefferson CountyKings CountyLewis CountyLivingston CountyMadison CountyMonroe CountyMontgomery CountyNassau CountyNew York CountyNiagara CountyOneida CountyOnondaga CountyOntario CountyOrange CountyOrleans CountyOswego CountyOtsego CountyPutnam CountyQueens CountyRensselaer CountyRichmond CountyRockland CountySaratoga CountySchenectady CountySchoharie CountySchuyler CountySeneca CountySt. Lawrence CountySteuben CountySuffolk CountySullivan CountyTioga CountyTompkins CountyUlster CountyWarren CountyWashington CountyWayne CountyWestchester CountyWyoming CountyYates County
Chose the RI county or counties you will focus on:*

Bristol CountyKent CountyNewport CountyProvidence CountyWashington County
Chose the MN county or counties you will focus on:*

Aitkin CountyAnoka CountyBecker CountyBeltrami CountyBenton CountyBig Stone CountyBlue Earth CountyBrown CountyCarlton CountyCarver CountyCass CountyChippewa CountyChisago CountyClay CountyClearwater CountyCook CountyCottonwood CountyCrow Wing CountyDakota CountyDodge CountyDouglas CountyFaribault CountyFillmore CountyFreeborn CountyGoodhue CountyGrant CountyHennepin CountyHouston CountyHubbard CountyIsanti CountyItasca CountyJackson CountyKanabec CountyKandiyohi CountyKittson CountyKoochiching CountyLac qui Parle CountyLake CountyLake of the Woods CountyLe Sueur CountyLincoln CountyLyon CountyMahnomen CountyMarshall CountyMartin CountyMcLeod CountyMeeker CountyMille Lacs CountyMorrison CountyMower CountyMurray CountyNicollet CountyNobles CountyNorman CountyOlmsted CountyOtter Tail CountyPennington CountyPine CountyPipestone CountyPolk CountyPope CountyRamsey CountyRed Lake CountyRedwood CountyRenville CountyRice CountyRock CountyRoseau CountySaint Louis CountyScott CountySherburne CountySibley CountyStearns CountySteele CountyStevens CountySwift CountyTodd CountyTraverse CountyWabasha CountyWadena CountyWaseca CountyWashington CountyWatonwan CountyWilkin CountyWinona CountyWright CountyYellow Medicine County
Chose the TN county or counties you will focus on:*

Anderson CountyBedford CountyBenton CountyBledsoe CountyBlount CountyBradley CountyCampbell CountyCannon CountyCarroll CountyCarter CountyCheatham CountyChester CountyClaiborne CountyClay CountyCocke CountyCoffee CountyCrockett CountyCumberland CountyDavidson CountyDecatur CountyDeKalb CountyDickson CountyDyer CountyFayette CountyFentress CountyFranklin CountyGibson CountyGiles CountyGrainger CountyGreene CountyGrundy CountyHamblen CountyHamilton CountyHancock CountyHardeman CountyHardin CountyHawkins CountyHaywood CountyHenderson CountyHenry CountyHickman CountyHouston CountyHumphreys CountyJackson CountyJefferson CountyJohnson CountyKnox CountyLake CountyLauderdale CountyLawrence CountyLewis CountyLincoln CountyLoudon CountyMacon CountyMadison CountyMarion CountyMarshall CountyMaury CountyMcMinn CountyMcNairy CountyMeigs CountyMonroe CountyMontgomery CountyMoore CountyMorgan CountyObion CountyOverton CountyPerry CountyPickett CountyPolk CountyPutnam CountyRhea CountyRoane CountyRobertson CountyRutherford CountyScott CountySequatchie CountySevier CountyShelby CountySmith CountyStewart CountySullivan CountySumner CountyTipton CountyTrousdale CountyUnicoi CountyUnion CountyVan Buren CountyWarren CountyWashington CountyWayne CountyWeakley CountyWhite CountyWilliamson CountyWilson County
Chose the VA county or counties you will focus on (choose "Other" if the city is not in a county:*

Accomack CountyAlbemarle CountyAlleghany CountyAmelia CountyAmherst CountyAppomattox CountyArlington CountyAugusta CountyBath CountyBedford CountyBland CountyBotetourt CountyBrunswick CountyBuchanan CountyBuckingham CountyCampbell CountyCaroline CountyCarroll CountyCharles City CountyCharlotte CountyChesapeake CountyChesterfield CountyClarke CountyCraig CountyCulpeper CountyCumberland CountyDickenson CountyDinwiddie CountyEssex CountyFairfax CountyFauquier CountyFloyd CountyFluvanna CountyFranklin CountyFrederick CountyGiles CountyGloucester CountyGoochland CountyGrayson CountyGreene CountyGreensville CountyHalifax CountyHanover CountyHenrico CountyHenry CountyHighland CountyIsle of Wight CountyJames City CountyKing and Queen CountyKing George CountyKing William CountyLancaster CountyLee CountyLoudoun CountyLouisa CountyLunenburg CountyMadison CountyMathews CountyMecklenburg CountyMiddlesex CountyMontgomery CountyNelson CountyNew Kent CountyNorfolk CountyNorthampton CountyNorthumberland CountyNottoway CountyOrange CountyPage CountyPatrick CountyPittsylvania CountyPortsmouth CountyPowhatan CountyPrince Edward CountyPrince George CountyPrince William CountyPulaski CountyRappahannock CountyRichmond CountyRoanoke CountyRockbridge CountyRockingham CountyRussell CountyScott CountyShenandoah CountySmyth CountySouthampton CountySpotsylvania CountyStafford CountySurry CountySussex CountyTazewell CountyVirginia Beach CountyWarren CountyWashington CountyWestmoreland CountyWise CountyWythe CountyYork CountyOther
Let us know if you want to drill deeper (note specific zip codes or cities/towns in the box below)
FOR GARITYADVANTAGE OFFICE USE ONLY:
Requested By
Approval Date

MonthDayYear
Date
Approved By
Approved Qty.
Additional Office Notes
Form Name
Should be Empty: