Intent to Enroll Form

Intent to Enroll Form

Fill a form for each policy you signed up for!
Full Legal Name*
Your Date of Birth*

MonthDayYear
Date of Birth
Insurance Type*
Carrier / Insurance Company*
Plan Name*
Premium / Rate*
Effective Date*
By signing below, I understand the following to be true and accurate...
- I am enrolling in the plan above and I hereby authorize my insurance agent/agency/broker: Teague Financial Insurance Services NPN 2746795 Lic#0754779 / April Hammett NPN 7992737 Lic#0E32088 to submit my enrollment application to the above stated carrier.
- My enrollment in Original Medicare Part A and Part B is required for me to purchase a a Medicare Advantage Prescription Drug plan (Part C: MAPD) or a Medicare Supplement plan (Part E: Medigap).
- My enrollment in Original Medicare Part A or Part B is required for me to purchase a Prescription Drug Plan (Part D: PDP).
- The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form or to my agent/ broker, I may be disenrolled from the plan and my insurance broker/agent is not liable.
- I understand that carriers may modify their benefits and/or rates. The carrier will communicate changes with me directly.
  Teague Financial does not represent or enroll members in Medicare. Medicare is a program offered by the Federal government and administered through Social Security Administration and CMS.
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