Senior Savings Network Questionnaire

1

Are you a Current Client of ours?

Yes

No

2

What can we Help you with?Thank you for being a valued client!

Review My Plan

Medicare Advantage or Part D Prescription Questions

Something Else

3

Which of following applies to your Medicare situation?

I am turning 65 within the next 6 months OR I have turned 65 within the last 6 months

I am under 65 and eligible for Medicare

I am considering leaving/losing employer (group) coverage and DO NOT already have Medicare Part B

I am considering leaving/losing employer (group) coverage and have had Medicare Part B in effect for more than 6 months

I am already on Medicare and want to shop my plan

Something Else

4

When did your Medicare Part B begin?

5

Is your current plan a Medicare Advantage (HMO, PPO, $0/mo) plan OR a Medicare Supplement (Plan F, Plan G, Plan N) plan?

Medicare Advantage

Medicare Supplement

6

Describe What We Can Help You With BelowPlease also include your name and contact information where we may reach you. (Email Address or Phone Number)

7

Name

First Name

Last Name

8

Phone Number

Area Code

Phone Number

9

Email

example@example.com