Medicare Quote Form
I understand that completion of this form is not required but it is needed if I’d like additional information regarding plan options or contact from a licensed Medicare sales agent. I understand that I am not required to complete this form and have done so at my discretion. By providing the information on this form, you are granting permission for a licensed insurance sales agent to call or email regarding Medicare Insurance Plan options including Medicare Supplement, Medicare Advantage, and Prescription Drug Plans. Your consent is voluntary and allows us to contact you via text messaging, artificial or prerecorded voice messages, or automatic dialing for marketing purposes. You may contact us to change your preferences at any time. Changing your preferences will not affect your eligibility for benefits and enrollment, payment for coverage of services, or ability to get treatment. Data use charges and rates from your cellular carrier may apply.
Beneficiary's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Please Select
Male
Female
Beneficiary's Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this also your physical address?
Yes
No, I live somewhere else
Beneficiary's Phone
*
Format: (000) 000-0000.
Beneficiary's Email
*
example@example.com
Do we have permission to communicate via text with you at this number?
*
Yes
No
Current Medicare & Medicaid Status
Medicare Part A Effective Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medicare Part B Effective Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is your Medicare ID Number
Do you receive Medicaid or extra help LIS (Low Income Subsidy) with your prescription drug costs?
Yes
No
Are you a Veteran? Is someone in your home a Veteran?
Yes
No
Please select your current plan(s).
Medicare Advantage (MAPD)
Original Medicare Parts A & B only
Medicare Supplement and Part D Prescription Drug Plan
Medicare Supplement but NO Drug Plan
Other
What is the current carrier name?
What is the current plan name?
Exact plan name if possible
How much are you paying for the plan per month? (if not $0 premium)
What do you like most and least about your current plan? Plan preferences:
Do you have any other health insurance coverage besides Medicare?
Yes
No
Prescription & Physician Information
Are there any prescriptions that you would like me to look up for you and make sure they're covered? If so, please list them below:
Rows
Prescription Name (Brand required?)
Dosage (cap/tab)
Monthly Quantity
Refill Frequency (30 days, 90 days)
Rx1
Rx2
Rx3
Rx4
Rx5
Rx6
Preferred Retail Pharmacy Name
Do you have a Primary Care Physician?
Yes
No
If yes, please provide the following information
Rows
Doctor Name
Practice Name
Practice Address
Primary
Specialist
Specialist
Specialist
Do you have any chronic illnesses that you would like to make me aware of?
Ex: diabetes, cancer, heart or lung disorders
Do you use any Durable Medical Equipment like Oxygen, CPAP, Diabetic Supplies?
Yes
No
Are you interested in having coverage for Dental, Vision or Hearing?
Dental
Vision
Hearing
Is there anything else you can think of that I should know about to be able to help you the best I can? What is most important to you in a plan?
Submit
Should be Empty: