New Multi-Plan Material Submission Request

Are you a Vendor or Insurance Agency? *

Please include Agency Name, NPN or EIN

Agency Name

Agency NPN

Agency EIN

If Adding a Vendor Please Include Following Information

Marketing Vendor Name

Marketing Vendor Email

Marketing Vendor Phone Number

Marketing Vendor Address

Contact Info of Requester

First Name *

Last Name *

Email *

Phone *

Please include NPN if individual agent submitting for themself

Agent NPN Number

Name of Agency or Group you are working with? *

Please Provide ALL Websites, URL's, Landing Pages, or Form Fills used to collect prospect information

Please separate multiple URLs with a comma. If no website is used place N/A

Prospect Facing URLs

Audience and Material Life Cycle Selection

Please select the intended Material Target Audience *

Current Members

Prospective Members

Select the Material Life Cycle *

Are carrier logos present in your submission?

Yes

Material Detail Information

Material ID

Material Description *

Material contains both Part C and Part D information? *

File Upload and Attestation

For website previews please a word document with all of the pages on your site including disclaimers and Permission to Contact Forms. Also, the Carrier requires to see all lead generation assets used to collect Member Information.

Choose file to upload *

Acknowledge before submitting:

Based on my knowledge, information, and belief, I attest that the material is complete, accurate, and truthful. This attestation applies to all requirements under the File and Use Certification process and other CMS guidance.