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
Format: (000) 000-0000.
E-mail
example@example.com
Upline
I intend to:
What type of Lists
List count requested:
State:
What county or counties would you like to focus on?
Chose the CT county or counties you will focus on:
Chose the MA county or counties you will focus on:
Chose the ME county or counties you will focus on:
Chose the NH county or counties you will focus on:
Chose the NY county or counties you will focus on:
Chose the RI county or counties you will focus on:
Chose the MN county or counties you will focus on:
Chose the TN county or counties you will focus on:
Chose the VA county or counties you will focus on (choose "Other" if the city is not in a county:

Other
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
Approved
Approval Date

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