Commission Inquiry

1
Carrier Name* This field is required.
Only one carrier per form
2
Request Date
Date
Year
Month
Day
3
Today's Date* This field is required.
4
Agent Name* This field is required.
First Name
Last Name
5
Agent Writing Number* This field is required.
6
Phone Number* This field is required.
Area Code
Phone Number
7
Email* This field is required.
example@example.com
8
What is this regarding?* This field is required.
AOR Error
Chargeback Issue
Missing Commissions
Missing Override
9
Client's Name* This field is required.
First Name
Last Name
10
Is there more than one person on the policy?
YESNO
11
Total number of people on this policy
12
Date of Birth* This field is required.
Date
Year
Month
Day
13
Product Type* This field is required.
Medicare Advantage
Medicare Supplement
PDP
Under 65 Health
14
Medicare or Policy Number* This field is required.Fields are provided later in the form for additional policy inquiries
15
Original Effective Date* This field is required.
Date
Year
Month
Day
16
Payment Due Date
Date
Year
Month
Day
17
Payment Type* This field is required.
Initial
Renewal
18
Additional PoliciesThese policies must be for the same Carrier and same Agent Writing Number
19
Additional Comments
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: