Use this form to check if your marketing plans are co-op eligible
Name
*
First Name
Last Name
Requestor's Email
*
example@example.com
CC Email - if needed
example@example.com
Phone Number
*
-
Area Code
Phone Number
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Upline Name
if not direct to GarityAdvantage
Briefly Describe Your Marketing Plan
*
Estimated Cost
*
Target Products
*
Medicare Advantage
Medicare Supplement
PDP
Final Expense
Other
Target Medicare Advantage Carriers (if applicable)
Aetna
Anthem/Empire
Blue Cross Blue Shield of Rhode Island
CarePartners of Connecticut
Emblem Health
Eon Health
Fallon Health
Harvard Pilgrim Health Care
Humana
Mutual of Omaha
UnitedHealthcare® Medicare Solutions
Wellcare
Other
Target Medicare Supplement Carriers (if applicable)
Aetna Senior Supplement
Anthem/Empire
Cigna
Combined
Globe Life
GPM Life
GTL
Harvard Pilgrim
Humana
Mutual of Omaha
TransAmerica
United American
UnitedHealthcare® Medicare Solutions
Other
Target Final Expense Carriers (if applicable)
Americo
Aetna Senior Supplement
Foresters
Gerber Life
Royal Neighbors of America
Other
Are you contracted through GarityAdvantage for these carriers/products?
*
YES
NO
Unsure
Did you discuss this marketing strategy/co-op with someone from GarityAdvantage?
*
YES
NO
Who?
*
Who is your Territory Manager?
*
Please Select
Bailey, Victoria
Feit, Jane
Gontarek, Theresa
Koteras, Tricia
Tyler, Jennifer
Young, Susan
Additional Questions/Comments
Submit
FOR GARITYADVANTAGE USE ONLY
Reviewed by
Review Date
-
Month
-
Day
Year
Date
Marketing:
is Co-op Eligible
is NOT Co-op Eligible
more information needed
Territory Manager
example@example.com
Notes
Should be Empty: