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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 submitting this form, you are requesting to have a licensed insurance sales agent contact you by telephone, email or cell phone to provide additional information about products and services.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, . Data use charges and rates from your cellular carrier may apply.
Are you already working with a team member at Schultze Agency? If so, select one:
Please Select
Jeff Schultze
Jaime Schultze
Brenner Brown
Not working with anyone
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do we have permission to communicate via text with you at this number?
*
Yes
No
If you are new to Medicare, what month will you be eligible for it? Write NA if not applicable
Have you created a Medicare.gov account?
Yes
No
https://www.medicare.gov/
Will you be receiving any Social Security benefits
Yes
No
I don't know
Do you have both Parts A and B and what are their effective dates?
I have only part A.
Yes I have both A and B
I have neither part A nor part B
Medicare Part A is free if you have at least 40 calendar quarters of work in any job where you paid Social Security taxes in the U.S., Are eligible for Railroad Retirement benefits, Or, have a spouse that qualifies for premium-free Part A. Do any of these apply to you? Yes or No
Effective dates Part A or B or both (NA if not applicable)
Do you currently receive health coverage through a former employer or organization?
How often do you go to the doctor or see a specialist?
Do you live part-time in another state or travel frequently?
Do you have a particular doctor, hospital, or pharmacy that you want to use? If so, please list below. Please include locations of specific doctors office.
Do you want to have your prescriptions checked? Each plan that includes drug coverage has a set formulary of generic and brand names that the plan agrees to cover. If yes, please fill out the following.
Yes
No
Which pharmacy do you use? List any that apply.
Please feel free to include any other information that you feel is valuable you wish for me to know before our appointment.
If you already have Medicare, PLEASE DO NOT PUT YOUR NUMBER HERE call the office to provide your Medicare number to me. 512-549-8700
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