Scope of Appointment Compliance Checklist Form
Complete this form to document a scope of appointment meeting, the parties involved, the appointment details, the product types discussed, and compliance confirmations.
Appointment Details
Appointment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Appointment Time
*
Hour Minutes
AM
PM
AM/PM Option
Appointment Location or Channel
*
Please Select
In-person
Phone
Virtual
Other
How Was the Appointment Initiated?
*
Beneficiary requested the meeting
Agent contacted the beneficiary
Other
Parties and Organizations
Beneficiary/Client Name
*
Agent/Broker Name
*
Organization/Carrier Name
*
Scope of Appointment Checklist
Method of Appointment
*
In Person
Phone
Video Call
Email
Mail
Other
Product Types Discussed
*
Medicare Advantage
Medicare Part D
Medicare Supplement
Hospital Indemnity
Critical Illness
Dental
Vision
Other
Compliance Confirmation
Confirmation: The scope of appointment was explained before discussing products
*
Confirmed
Attestation: The information is accurate and the appointment followed the scope of appointment process
*
Confirmed
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