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:

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)
BULK SUPPLIES NEEDED TO CREATE YOUR OWN CUSTOM KITS – SILVER/BRONZE HSA and PERSONALCARE Quantity / 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)