Agent App
Full Name
*
First Name
Last Name
Email
Mobile
*
Home
Client ID
Date of Birth
*
MM slash DD slash YYYY
Mailing Address
*
Street Address
P.O. Box
City
State
Alabama
Alaska
Arizona
Arkansas
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Washington
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
County
Physical Address
Street Address
P.O. Box
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
County
Notes
Medicare Number
*
Medicaid Number
Medicare Username
Medicare Password
Effective Date
*
MM slash DD slash YYYY
Closing Date
*
MM slash DD slash YYYY
Medicare Effective A
*
MM slash DD slash YYYY
Medicare Effective B
*
MM slash DD slash YYYY
Original Premium Amt
LIS Premium Amt
Level of L.I.S
Level of Medicaid
Requires Prior Authorization
*
Yes
No
Pre Authorization Med 1
Pre Authorization Med 2
Pre Authorization Med 3
PCP Name
*
PCP Phone
*
New PCP
*
NA
No
Yes
Insurance Type
MedAdvantage
MedSupp
MedSupp Carrier
Mutual Of Omaha
Transamerica
Cigna
Aetna
Other
MedSupp Plan Type
Plan G
Plan F
Plan N
Other
MedSupp Premium
MA Carrier
United Healthcare
Humana
Anthem
Wellcare
Aetna
Amerivantage
CareNeeds
Oscar Health
MA Plan Type
PPO
HMO
SNP
DSNP
POS
MA Plan Name
*
First Time MA
NA
No
Yes
AOR Change
NA
No
Yes
Dental / RX / Dental & RX / Hosp Indem
None
Dental
RX
Dental & RX
Hospital Indemnity
Dental Carrier
Ameritas
Mutual Of Omaha
GPM
Manhattan
United Healthcare
Other
Dental Premium
Dental Effective Date
MM slash DD slash YYYY
RX Part D Carrier
Humana Walmart
Cigna Health Spring
WellCare
Aetna
Silver Script
AARP
Humana
UHC
Express Scripts
Magellan
First Health
Mutual of Omaha
Other
Rx Part D Premium
RX Part D Effective Date
MM slash DD slash YYYY
Sales Type
*
NA
Facebook Live
DR Transfer
AutoDialer Outbound
CallerID Callback
Agent Callback
Voicemail Live
SMS Live
SMS 2-Way Channels
Other
Retention Denise
Retention Francis
MGL Mailer
Mailer-20200215
Chase User (first initial & last name)
*
Selling Agent
*
Aberardino
Abrillantino
Ajerez
Bcampbell
Bcortazar
Bjaffy
Bcouyoute
Cramirez
Csimone
Dherzer
Dquinn
Droberts
Emaurer
Fgriffin
Gmitchell
Jdaccolti
Hvaltez
Jdelisca
Jsimon
Jstein
Kfletcher
Kbrooks
Lpereira
Lsorto
Mfischer
Mfox
Mpatel
Mpikounis
Msarikas
Npilja
Rcancel
Seder
Smarra
Shernandez
Sramirez
Tdumas
Vparadis
Vthomas
Retention-Francis
Retention-Denise
Not Listed
Selling Agent Name (Not Listed)
Agent Of Record Full Name
*
CONFIRMATION ID
Comments
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