Commission Inquiry Request Form

Commission Inquiry Request

Contact us if you have questions about how to complete: 800-234-9488
Agent First Name*
Agent Last Name*
Agent E-mail*
Alt E-mail for CC:
example@example.com
Agent Phone Number*

Area CodePhone Number
How many policies would you like to inquire about?*

OneMore than One
For a single policy inquiry: Complete all of the fields below and hit submit. Allow 48 hours for a response.
Carrier*
"Other" Carrier
Writing ID*
Agent Writing Number for Selected Carrier
Member Name*

First NameLast Name
Member Date of Birth*

MonthDayYear
Policy # or Medicare #*
Plan Type*
Policy Effective Date or Application Date*

MonthDayYear
Issue (ex. Missing renewal, True-up, month)*
To inquire on multiple policies, download the Commission Inquiry Template (Excel file) here. Complete ALL of the fields, save the file and upload to this form by clicking the button below. Contact us if you have questions. 800-234-9488
Upload the Completed Commission Inquiry Template*

Upload a File

Cancelof
Form Submitted By*

First NameLast Name
FOR GARITYADVANTAGE USE ONLY
Staff Assigned

First NameLast Name
Status
Should be Empty: