The agent should be the only one filling this form out. This intake form should only be used when you write a member outside of IFG sunfire so that your member will be in the CRM and it will trigger automations.

First Name *

Last Name *

Cell Phone *

Email *

Address *

City *

State *

Postal code *

Medicare number

Medicare Part A Date

Medicare Part B Date

Medicaid number

Carrier Name

Plan Name

Effective Date

Agent NPN