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 |
| | | |
| | | |
| | | |
| |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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