Type of Mailer: -Select Mailer- Dual Eligible Medicare Advantage Turning 65 AEP Mail Piece Code Mailer Format: BiFold - White BiFold - Pink BiFold - Blue Demographic Selections If you ran your own count, enter query number: OR fill out demographics below: Age: Date of Birth: Income Range: Omit PO Boxes: -Select- Yes No Phone Numbers: -Select- Yes No Other: ZipCodes, SCF and/or County: Separate all zip codes, SCFs and/or counties using a comma. List in order of preference. Order Quantity & Totals Number to Mail: @ Total = /M If quantity is 500-999, add $50 flat set up fee. If under 500, add $100 set up. Does not include shipping/handling or tax for TX orders. Duplicate List Options Hard Copy - $25/M Email - $15/M Labels - $25/M Additional Options Print Phone #'s (where available) on card - $10/M Street Sequence on duplicate list - $3/M Print DOB month/year on duplicate list - $10/M Select Homeowners Only - $10/M Select by Gender - $3/M Notes/Special Instructions Billing and/or Shipping Address Company: Name: Address: City: State: Zip Code: Phone #: Fax #: Email: Payment Method: -Select Payment- Check Credit Card Note: We will contact you for card information. Order is subject to zip code availability under our 90 day file protection policy Send Order Confirmation By: -Select- Email Fax I have seen a Mail Piece Sample: -Select- Yes No Submit
