Sales/Marketing Event Submission
E-mail to: events@appliedga.com | Fax to: 1-877-342-9978
LAST UPDATED: 11042019JT
Aetna
Blue Shield Central Health Humana UnitedHealthcare
Alignment
Blue Shield Promise CIGNA Inter Valley WellCare
Allwell Brand New Day Golden State SCAN Other:_________________________
CARRIERS TO BE PRESENTED
Informal Sales Event Formal Sales Event Educational Event
(no meals)
EVENT TYPE
Date Received Date Submitted Notes
FOR OFFICE USE ONLY
All agents must report all sales and marketing activities scheduled to AGA. This form must be returned to AGA by the 15th of the month PRIOR
to your event. Any submission turned in after the 15th is subject to denial by carrier. Fill out the form completely. Your event cannot be
reported to CMS without ALL requested information.
Agent Name Agent Phone
Agent E-Mail Presentation Language
Date of Event Start Time End Time Venue Contact and Title
Venue Name Venue Phone Venue County
Venue Street Venue City Venue State Venue Zip Code
Description of Venue Venue Capacity
Handicap Accessible
Type of Advertising and Start Date
Will the event be advertised?
Yes
No
Yes
No
AM
PM
AM
PM
PLEASE NOTE: AGA can no longer report on the agent’s behalf to Anthem Blue Cross and CareMore.
DSNP Health Fair Low-Income Subsidy (LIS)
EVENT DESCRIPTION
Additional Event Information
Medicare 101 Table Sit O th e r : _______________________________
