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0209
PLEASE NOTE: Most materials are available online for immediate download (DOWNLOAD NOW) and may not available through Supply. Applications are available through state Compliance Sheets. Material availability may vary by state. Please refer to your state's Compliance Sheet or Product Approval Chart before ordering. STEP 1: Fill in the yellow and blue boxes below. All information is required. Please complete a separate UAatWork Supply Order Form for each state where you are licensed.
AGENT NUMBER
BRANCH NAME
BRANCH NUMBER
ORDER DATE
YOUR NAME
# LICS. AGENTS
SUITE
CITY
ZIP
E-MAIL ADDRESS
CELL PHONE
OFFICE PHONE
FAX
BOD
F4397 R0209
STEP 2: Enter the quantity your are requesting to the right of each item. Then e-mail the completed form as an attachment to uaagentsupply@torchmarkcorp.com. (From the "File" menu above, select "Send To", then select "Mail Recipient as Attachment".)
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REQUIRED FORMS
Life and Health Privacy and Disclosure Booklet UAPDI F5616 HIPAA Release Authorization F3978 Rated Premium Rider Worksheet U-1280 WSM
DOWNLOAD ONLY
PRODUCT MATERIALS
Where approved, applications and other required forms can be downloaded from your state's Compliance Sheet. Select your state from the drop down menu displayed on the web page.
UAMG
Application UAMG[XX] Optional Dependent Form UAMG-ODF[XX] Health Rate Card F4434[XX] Foundation (MMGAP/R-MMGAP-HO) Product Brochure F6546[XX] Outline of Coverage DS-MMGAP[XX] Marketplace Bulletin F6608 WSM MMGAP
DOWNLOAD ONLY DOWNLOAD ONLY DOWNLOAD ONLY
UAMM
Application UAMM[XX] Optional Dependent Form UAMM-ODF[XX] Health Rate Card F4434[XX] Life Rate Book F4702[XX] Foundation (MMGAP/R-MMGAP-HO) Product Brochure F6546[XX] Outline of Coverage DS-MMGAP[XX] Marketplace Bulletin F6608 WSM MMGAP Life - 20 Year Renewable Term & Term to 100 (UATPTL/UATGC) Product Brochure F6550 Marketplace Bulletin F6604 WSM UAPTL Marketplace Bulletin F6605 WSM UAPTGC
DOWNLOAD ONLY DOWNLOAD ONLY DOWNLOAD ONLY DOWNLOAD ONLY
DOWNLOAD ONLY
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UAGP
Application UAGP[XX] Optional Dependent Form UAGP-ODF[XX] Health Rate Card F4434[XX] FLEXguard (GSP2) Product Brochure F4631[XX] Outline of Coverage DS-GSP2[XX]R
DOWNLOAD ONLY DOWNLOAD ONLY DOWNLOAD ONLY
DOWNLOAD ONLY
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Surgical Expense Series (SSXC) Product Brochure F4344[XX] Outline of Coverage DS-SSXC[XX] Surgical Medical Series (SMXC) Product Brochure F4345[XX] Outline of Coverage DS-SMXC[XX] Protector Series I (HMXC) Product Brochure F4346[XX] Outline of Coverage DS-HMXC[XX] Protector Series II (HIXC) Product Brochure F4347[XX] Outline of Coverage DS-HIXC[XX]