ARC New Business Submission Form – americanretirementcounselors.net

New to ARC

New to ARC

Merge Lead Record

Merge Lead Record

Google Review

Contact for Google Review

Uninsured Policy Owner

Uninsured Policy Owner

Multiple Insureds

Multiple Insureds

Primary Insured Information

Primary Insured Full Name *

First

Middle

Last

Primary Insured DOB *

Primary Insured SSN

MedicareID/MBI

Medicare Part A Effective Date

Medicare Part B Effective Date

Primary Phone *

Primary Phone Type *

Secondary Phone

Secondary Phone Type

Primary Insured Email

Lead Source *

Primary Insured Resident Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Insured Mailing Address (If different than Resident Address)

Address Line 1

Address Line 2

City

State

Zip Code

Uninsured Policy Owner Information

Uninsured Owner Full Name *

First

Middle

Last

Uninsured Owner DOB

Uninsured Owner SSN

Uninsured Owner Email

Primary Phone

Primary Phone Type

Uninsured Owner Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Additional Insureds Information

Additional Insured 1 Full Name *

First

Middle

Last

Additional Insured 1 DOB

Additional Insured 1 SSN

Additional Insured 1 Email

Primary Phone

Primary Phone Type

Add Another Insured 1

Add Another Insured

Additional Insured 2 Full Name *

First

Middle

Last

Additional Insured 2 DOB

Additional Insured 2 SSN

Additional Insured 2 Email

Primary Phone

Primary Phone Type

Add Another Insured 2

Add Another Insured

Additional Insured 3 Full Name *

First

Middle

Last

Additional Insured 3 DOB

Additional Insured 3 SSN

Additional Insured 3 Email

Primary Phone

Primary Phone Type

Add Another Insured 3

Add Another Insured

Additional Insured 4 Full Name *

First

Middle

Last

Additional Insured 4 DOB

Additional Insured 4 SSN

Additional Insured 4 Email

Primary Phone

Primary Phone Type

Add Another Insured 4

Add Another Insured

Additional Insured 5 Full Name *

First

Middle

Last

Additional Insured 5 DOB

Additional Insured 5 SSN

Additional Insured 5 Email

Primary Phone

Primary Phone Type

Product Information

Carrier & Product *

Coverage Type *

MA/MAPD Only *

New (to CMS)
Replacing (to CMS)

** All Medicare-Related Business MUST have a signed and dated Scope of Appointment Form submitted with application documents
** All Scope of Appointment Forms MUST be signed and dated 48 hours prior to your appointment

Premium (Modal) *

Pay Frequency (Premium Mode) *

Premium (Annual) *

Policy Number (If Provided)

Application Type *

Paper App
eApp
Tele-App

Transaction Type *

Application Signed Date *

Proposed Effective Date *

Agent Information

Signing Agent *

Servicing Agent/Agent of Record *

Servicing Agent Email *

Servicing Agent Split *

Servicing Agent Expected FYC *

Additional Agent/Field Trainer

Additional Agent/Field Trainer

Field Trainer

Field Trainer

Additional Agent/Field Trainer *

Additional Agent Email *

Additional Agent Split *

Additional Agent Expected FYC *

Application Documents

** All Medicare-Related Business MUST have a signed and dated Scope of Appointment Form submitted with application documents
** All Scope of Appointment Forms MUST be signed and dated 48 hours prior to your appointment

Application Documents

Click or drag files to this area to upload. You can upload up to 10 files.

Notes