Request A Call During Annual Enrollment Period (AEP)

Request A Call During Annual Enrollment Period (AEP)
Complete this form to be contacted during AEP, October 15th - December 7th, to review your Medicare plan options. If wanting to schedule a call during a specific date / time, please complete the form Schedule A Medicare Review During AEP .
Name*

First NameLast Name
Phone Number*
E-mail
example@example.com
What Medicare products are you interested in discussing? The Centers for Medicare and Medicaid Services (CMS) requires licensed sales agents to document the scope of the products that may be presented during a marketing appointment.*

Standalone Prescription Drug Plans (Part D)Medicare Advantage (Part C)Medicare Supplements
What state do you reside in?*
What is your preferred pharmacy of choice?
Additional Comments
By completing this form, you agree to be contacted by a licensed sales agent to discuss the types of products you indicated above. Please note, the individual who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the federal government. This individual may also be paid based on your enrollment in a plan. Completing this form does not obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan.
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