Agent Client Tracking System

Agent Client Tracking System

AGENT CUSTOMER TRACKING FORM

All orders sold MUST be entered online on a weekly basis AND the originals MUST be mail or fax in 24-48 hours to be paid. If this process is not followed you will not be paid a commission.

Agent Name
State Product Sold
Customer First Name
Customer Middle Name
Customer Last Name
Address
Address 1
City
Zip Code
SSN
Birth Date
Phone Number
Gender
Medicare ID #
Medicare Effective Date Part A
Medicare Effective Date Part B
Medicade ID #
Application Date
Effective Date
Product Sold
Plan Type
Premium Amount
Agent Producer ID
Agent Phone Number

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