2024 Medicare Agent Supply Order Form

Agent Supply Order Form

If you are looking for Employer Group MAPD supplies, please place your order here.

If ordering non-group supplies, please continue with the form below.

1. First Name *This question is required.

2. Last Name *This question is required.

3. Email Address *This question is required. This question requires a valid email address.

4. Phone Number *This question is required.

Please note: we CAN NOT make deliveries of supply orders to PO boxes.

5. Agency Name *This question is required.

6. Street Address - NO PO boxes *This question is required.

7. Suite #

8. City *This question is required.

9. State *This question is required.

10. Zip *This question is required. This question requires a valid number format.

11. Detail any specific delivery instructions below Note: this is for delivery instructions ONLY - please do not include additional requests pertaining to your order.

12. Are you are an Elite Agent? *This question is required.

13. Please enter your Elite Agent Number *This question is required.

13. How many MAPD $0 plan pre-enrollment packets would you like? Max of 50. This question requires a valid number format.

13. How many MAPD $0 plan pre-enrollment packets would you like? Max of 25. This question requires a valid number format.

13. How many Premium plan pre-enrollment packets would you like? Max of 10.
(Plans with a monthly premium: PriorityMedicare Ideal, PriorityMedicare, PriorityMedicare Merit, PriorityMedicare Select, and PriorityMedicare Value) This question requires a valid number format.

13. How many DSNP pre-enrollment packets would you like? Max of 10. This question requires a valid number format.

13. How many Medigap Pre-enrollment packets would you like? Max of 10. This question requires a valid number format.

13. How many Dental & Vision pre-enrollment packets would you like? Max of 5. This question requires a valid number format.