Schedule A Call During Annual Enrollment Period (AEP)

Schedule A Call During Annual Enrollment Period (AEP)

Complete this form to schedule a set date / time to be contacted to review Medicare plan options during Annual Enrollment Period (AEP), between October 15th - December 7th.
Full Name*

First NameLast Name
Phone Number*

Area CodePhone 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 Plans (Part C)Medicare Supplements
What state do you reside in?*
What is your preferred pharmacy of choice?
Please Select an Appointment Date and Time
By requesting an appointment, 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.
Additional Information/Comments
Should be Empty: