P.O. Box 2271 Omaha, NE 68103-2271
Call 1-877-617-5592, ext. 2186 Fax order to 1-402-351-2456
Use to Order Medicare Supplement Prospecting Newspaper Ad and/or Postcard Gerber Life Insurance Company offers you one state-approved newspaper ad and one postcard to promote our Medicare supplements. Check Web site for availability at www.gerberlifegroup.com
To Order: Step 1: Request form must be completed in full – both pages required for postcard. if not completed in full, your request will be delayed. Step 2: Fax this order form to 1-402-351-2456. Step 3: You will be e-mailed a PDF to review for accuracy and approval for printing. If response is not received within 30 days, your request will be canceled. Step 4: Please allow 5 to 7 days for your newspaper ad and 3 to 4 weeks for your postcards.
Producer Material Is Being Requested For (Required) Name ______E-mail Address (to review and approve order) ______Daytime Phone Number______Producer Number ______
Requested By: (complete only if you are ordering for producer above) Name ______E-mail Address ______Daytime Phone Number______ Check here if you want to be copied on approval
Newspaper Ad Order Please note: This ad has been filed and approved by your state insurance department and cannot be modified in any way. If newspaper ad is modified, it will not be state or corporate compliant.
Rates
We provide the nontobacco rates and disclosure based on the information you provide here.
State ZIP codes for ZIP- Age(s) (limit 3) Check one: Med supp plan(s) rated states F Male rates (limit 2) F Female rates
Ad Dimensions Dimensions of ad you require in inches: width ______height ______• Minimum size: 4.5” wide x 5.75” high. • Please verify the ad size space available in inches (not columns) with your newspaper. • We can increase the ad to fit a larger space. If there is a publication deadline, please indicate it here ______
T03_248_0610 For producer use only. Not for use with the general public. 1 NOTE: AGENCY NAME: If utilizing an Agency Name on your prospecting pieces, the Agency Name must be listed in your up-line within your hierarchy on Gerbers’s records. If your hierarchy does not currently reflect the Agency Name, you will need to contact your MGA to obtain the appropriate paperwork required by Gerber to have the agency added to your hierarchy. Once the appropriate paperwork is filled out, your MGA will forward this paperwork to Producers Services at Gerber for processing. The following requirements must be met to set up an agency on Gerber’s records: ● Agency must hold a valid state insurance license ● Agency must be assigned a valid Tax-Id number
Contact information to be included on the newspaper ad Agency Name______Agent Name______Phone Number ______
Postcard Order (Postcard dimensions are 9” x 6” and costs .44 to mail)
Quantity (maximum 5,000) ______
Rates ● We provide the nontobacco rates and disclosure based on the information you provide here. ● M and N plans cannot be advertised on these pieces State ZIP codes for ZIP- Age(s) (limit 3) Check one: Med supp plan(s) rated states F Male rates (limit 2) F Female rates
Contact information to be imprinted on the postcard Agency Name______Agent Name______Phone Number ______
Return Address to have imprinted on the postcard Agency Name______Agent Name ______Street Address ______City, State, ZIP ______
Bulk Rate Permit (optional) Not required – complete only if you have a permit.
F Presort Standard or Permit # City of Origin F Presort First Class
Shipping Instructions via UPS Company______Attention______Street Address (cannot ship to a P.O. box) ______City, State, ZIP ______
T03_248_0610 For producer use only. Not for use with the general public. 2