Producer Supply Order Form - Individual



|REQUESTOR: |

|Today’s Date |      | | | |

|Producer Name |      |Agency Name |      | |

|Address |      | |

|City |      |State |   |ZIP |      | |

|Producer phone # |      |Producer number |      | |

|Producer email # |      | | |

|MUST PROVIDE STREET ADDRESS – NO PO BOX – ITEMS SENT VIA UPS |

| Check box to indicate NO SIGNATURE REQUIRED for delivery |

Individual―Producer Supply Order Form

Please fax your request to 425-918-3378

E-mail: producer.support@

|SALES BROCHURE/PRESENTATION FOLDER – 1/1/16 effective dates and after |Quantity |Item # |

|DOES NOT INCLUDE RATE SHEETS OR ENROLLMENT APPLICATION |     |015382 |

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| |BULK SUPPLIES NEEDED TO CREATE YOUR OWN CUSTOM KITS – GOLD, SILVER, BRONZE | |

| |Quantity |Quantity |

| |Sales Brochure |     |005914 (10-15) |Gold, Silver, Bronze Area 1,5 rates |     |027376 (4-15) |

| |Presentation Folder |     |027990 (8-14) |Gold, Silver, Bronze Area 2,3 rates |     |027377 (4-15) |

| |Enrollment Application |     |027108 (10-15) |Gold, Silver, Bronze Area 4 rates |     |027378 (4-15) |

| |Adult Dental Brochure + rates |     |027593 (10-15) |Pre-paid application envelope |     |035510 |

| |Kids Dental Brochure + rates |     |031542 (5-15) |Carrier Envelope |     |014992 |

| |Gold Preferred Plan Summary |     |027833 (4-15) | | | |

| |Silver Preferred Plan Summary |      |027835 (4-15) | | | |

| |Bronze Preferred Plan Summary |      |027832 (4-15) | | | |

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| |BULK SUPPLIES NEEDED TO CREATE YOUR OWN CUSTOM KITS – SILVER/BRONZE HSA and | Quantity | |

| |PERSONALCARE Quantity | | |

| |HSA Silver Plan Summary |     |027834 (4-15) |PersonalCare Gold Plan Summary |     |033342 (10-15) |

| |HSA Bronze Plan Summary |     |033346 (4-15) |PersonalCare Silver Plan Summary |     |033344 (10-15) |

| |HSA Area 1,5 rates |     |027382 (4-15) |PersonalCare Bronze Plan Summary |     |033337 (10-15) |

| |HSA Area 2,3 rates |     |027383 (4-15) |PersonalCare rates King County |     |033375 (4-15) |

| |HSA Area 4 rates |      |027384 (4-15) |PersonalCare rates Pierce, Snohomish |     |033378 (4-15) |

| |Value of HSA flyer |      |027993 (5-15) | | | |

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