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Name *

First Name

Last Name

Date of Birth *

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Phone *

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I'm interested in help with... *

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Medicare Advantage Plans (Part C)

Stand-alone Medicare Prescription Drug Plan

Ancillary Products (Dental/Vision/Hearing Products)

Medicare Supplement or (Medigap) Products

Hospital Indemnity Products

Life Insurance

Do currently have Medicare? *

YES

NO

Scope of Appointment Confirmation *

By signing this form, you agree to a meeting with a licensed sales agent to discuss the types of products you indicated above. Please note, the individual who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the federal government. This individual may also be paid based on your enrollment in a plan. Signing this form does not obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan.

Yes, I would like to have a Licensed Benefit's Specialist call, text, or email me.