Consent to Contact Form

Consent to Contact Form

for Mar Ramirez
As an independent Medicare plan advisor, I can help you learn the basics of Medicare and/or explore the plans available to you. I'll get you all the information you need to make confident decisions about your coverage.

And, as always, there is no cost or obligation to you for my assistance.

By completing this form, I expressly consent to the sharing of my personal beneficiary information and to being contacted by Mar Ramirez of Loyalty Insurance Marketing Group an independent, licensed insurance agent.
Name

First NameLast Name
City/State

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Email
example@example.com
Medicare regulations require that we obtain your consent before we contact you to discuss Medicare Advantage plan(s).

PLEASE NOTE: This Consent to Contact Form is optional. Submitting this optional form does NOT obligate you to enroll in a plan, affect your current or future Medicare enrollment, or automatically enroll you in a plan.

By completing this form, your information will be provided to Mar Ramirez, a licensed insurance agent. You may be contacted by Mar Ramirez who is a licensed and certified representative of Medicare Advantage organizations and/or stand-alone Prescription Drug Plans. Each of the organizations they represent has a Medicare contract.

Not affiliated nor endorsed by Medicare or any government agency.
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