Medicare Supplement Incentive Verification Form

Before you submit, please verify that these criteria are met:

  1. See your specific incentive flyer for the required number of policies to redeem your incentive.
  2. You are appointed through Network Insurance Senior Health Division with the carriers you wrote the policies with at the time the policies were written.
  3. Effective dates that qualify: 2/1 – 12/1 2022. Incentive must be redeemed by January 31st 2023.

  • Agent Info

  • Policy Information

  • Please enter the information for each policy into their respective fields as labeled below.

    More policies can be added by clicking the icon for each one you wish to add. To remove a policy, simply click the icon.

    CarrierAgent NumberMember NameEffective DatePolicy Number 
  • Please provide any comments, explanations, or additional info pertaining to the policies you are submitting.

For agent use only. Not for use with consumers. Certain exclusions and limitations may apply. Not affiliated with the United States government or the federal Medicare program. Enrollments for this promotion must be issued with carriers the agent is directly appointed with through Network Insurance at the time the policies were written. Applications may only be used once and may not be combined with any other promotion. Agent must be trained and certified and must abide by Network Insurance’s compliance program described at www.nishd.com/compliance.

B02051802