Producer Supply Order Form - Medicare
2018 Medicare Supplement: Producer Supply
Order Form (Alaska)
Please fax your request to 425-918-3378
E-mail: producer.support@
|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 |
|SUPPLIES NEEDED | | | |
| | |Quantity Requested |Item # | |
| | | | | |
| |*Carrier Envelope | |021246 (05-2017) | |
| |*The above item must be ordered separately. | | | |
| | | |
| | | |
| | | |Item # | |
| | |Quantity Requested | | |
| |Medicare Sales kit – For effective dates of 1/1/18 and after |New | | |
| | | | | |
| | | |015282 (10-2017) | |
| |Sales Brochure | |021149 (05-2017) | |
| |Outline of Coverage | |021151 (10-2017) | |
| |Producer Cover Letter | |021352 (10-2017) | |
| |Enrollment Application | |021150 (09-2017) | |
| |Return Envelope | |016328 (05-2017) | |
| | | | | | |
| | | | | | |
| |Comments: | | | | |
| | | |
| | | |
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