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1
Please Read - It's the Legal Stuff

By providing your name and contact information you are consenting to receive calls, text messages and/or emails from a licensed insurance agent about Medicare Plans at the number provided, and you agree such calls and/or text messages may use an auto-dialer or robocall, even if you are on a government do-not-call registry. This agreement is not a condition of enrollment.

Not connected with or endorsed by the United States government or the federal Medicare program. This is a solicitation of insurance and your response may generate communication from a licensed producer/agent.
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Your Name* This field is required.
First
Middle
Last
Suffix
3
Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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E-mail
5
Date of Birth00/00/0000
Month
Day
Year
6
What is Your Current Age
7
What is your gender?
Male
Female
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Please Provide Your Contact Numbers:Please list out your contact phone numbers in order of the preference we call. After the number please indicate if this number is your Home, Office or Mobile. Don't forget the Area Code.
Phone Number One
Phone Number Two
Phone Number Three
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Status
Single
Married
Divorced
Widowed
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Do you currently have group/individual insurance, Medicare Supplement or Med Adv plan?
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What is the name of your Pharmacy?
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Start date for current insurance?Doesn't have to be exact, so close is okay.
Date
Month
Day
Year
13
End date for current insurance?
Date
Month
Day
Year
14
What is your Medicare number? If you have one.
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Part A Start Date:
Date
Month
Day
Year
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Part B Start Date:
Date
Month
Day
Year
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Prescribed MedicationsPlease list all medications (DRUG NAME, DOSE, WHAT IS THE FREQUENCY THAT YOU TAKE IT? HOW MANY TIMES IS IT PRESCRIBED IN A YEAR) that you are currently prescribed, if more than one, separate them with a comma. If not applicable type in N/A
Doctor
Drug
Generic Y/N
Dosage
Frequency
Rx for 30 or 90 days
Med-1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Med-2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Med-3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Med-4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Med-5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Med-1
Med-2
Med-3
Med-4
Med-5
Doctor
Row 0, Column 0
Drug
Row 0, Column 1
Generic Y/N
Row 0, Column 2
Dosage
Row 0, Column 3
Frequency
Row 0, Column 4
Rx for 30 or 90 days
Row 0, Column 5
Doctor
Row 1, Column 0
Drug
Row 1, Column 1
Generic Y/N
Row 1, Column 2
Dosage
Row 1, Column 3
Frequency
Row 1, Column 4
Rx for 30 or 90 days
Row 1, Column 5
Doctor
Row 2, Column 0
Drug
Row 2, Column 1
Generic Y/N
Row 2, Column 2
Dosage
Row 2, Column 3
Frequency
Row 2, Column 4
Rx for 30 or 90 days
Row 2, Column 5
Doctor
Row 3, Column 0
Drug
Row 3, Column 1
Generic Y/N
Row 3, Column 2
Dosage
Row 3, Column 3
Frequency
Row 3, Column 4
Rx for 30 or 90 days
Row 3, Column 5
Doctor
Row 4, Column 0
Drug
Row 4, Column 1
Generic Y/N
Row 4, Column 2
Dosage
Row 4, Column 3
Frequency
Row 4, Column 4
Rx for 30 or 90 days
Row 4, Column 5
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Specialists & Other Physicians CarePlease list out the other doctors you see for additional care.
Doctors Name
Specialty Field
Clinic/Practice Name
Address
City
State
Zip Code
Phone
Physician #1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Row 0, Column 5
Row 0, Column 6
Row 0, Column 7
Physician #2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Row 1, Column 5
Row 1, Column 6
Row 1, Column 7
Physician #3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Row 2, Column 5
Row 2, Column 6
Row 2, Column 7
Physician #4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Row 3, Column 5
Row 3, Column 6
Row 3, Column 7
Physician #6
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Row 4, Column 5
Row 4, Column 6
Row 4, Column 7
Physician #1
Physician #2
Physician #3
Physician #4
Physician #6
Doctors Name
Row 0, Column 0
Specialty Field
Row 0, Column 1
Clinic/Practice Name
Row 0, Column 2
Address
Row 0, Column 3
City
Row 0, Column 4
State
Row 0, Column 5
Zip Code
Row 0, Column 6
Phone
Row 0, Column 7
Doctors Name
Row 1, Column 0
Specialty Field
Row 1, Column 1
Clinic/Practice Name
Row 1, Column 2
Address
Row 1, Column 3
City
Row 1, Column 4
State
Row 1, Column 5
Zip Code
Row 1, Column 6
Phone
Row 1, Column 7
Doctors Name
Row 2, Column 0
Specialty Field
Row 2, Column 1
Clinic/Practice Name
Row 2, Column 2
Address
Row 2, Column 3
City
Row 2, Column 4
State
Row 2, Column 5
Zip Code
Row 2, Column 6
Phone
Row 2, Column 7
Doctors Name
Row 3, Column 0
Specialty Field
Row 3, Column 1
Clinic/Practice Name
Row 3, Column 2
Address
Row 3, Column 3
City
Row 3, Column 4
State
Row 3, Column 5
Zip Code
Row 3, Column 6
Phone
Row 3, Column 7
Doctors Name
Row 4, Column 0
Specialty Field
Row 4, Column 1
Clinic/Practice Name
Row 4, Column 2
Address
Row 4, Column 3
City
Row 4, Column 4
State
Row 4, Column 5
Zip Code
Row 4, Column 6
Phone
Row 4, Column 7
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Questions or Concerns?If you just a question ask it here, then just click through to the end of the form and hit Submit! If you would like us to do some homework before we talk keep filling out this form. We know it's a pain but hopefully this will be as bad as it gets.
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