UMASS - InsMed Insurance Agency

UMass Chan Medical School

Department Coordinator Support Form

"Guaranteed Issue” Portable Disability Benefit Program for residents and fellows. Please help us understand how we can best serve your department:

First Name(Required)

Last Name(Required)

Email(Required)

Hospital Name(Required)

Department(Required)

Preferred Mode of Contact(Required)

Email

Office number

Cell phone

Office number(Required)

Cell phone(Required)

Would you like to arrange an educational lecture for your department?

Yes

No

Is there a location in your department where a poster about this program can be displayed?

Yes

No

Would you prefer to speak with your dedicated InsMed representatives on site or remotely about how to best serve your department?

On site

Remotely

Preferred Days to be Contacted (check all that apply):

Monday

Tuesday

Wednesday

Thursday

Friday

Would you like to include your Training Program Administrator (TPA) in this conversation ?

Yes

No

List name here:

Additional Comments

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