Permission to Contact

Permission to Contact about Medicare Plans

Laughlin Insurance, Inc. (503) 282-0827 | 10746 NE Halsey St. Portland, OR 97220
Medicare Beneficiary Name *
Email: *
example@example.com
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I am interested in plan information for the following (check all that apply): Plan availability may vary by location*

Medicare Advantage Plans (Part C)Stand Alone Medicare Prescription Drug Plan (Part D)Medicare Supplement (Medigap) PlanDental-Vision-Hearing Products
I understand that I may be contacted via the following methods (please check all that apply)*

Phone Call (mobile/home)EmailText Message
According to Medicare rules, we need your permission to contact you to discus your Medicare plan options. By accepting this form, you are agreeing to a sales telephone call or an email from a licensed sales agent to discuss the specific types of products above. The person who will be discussing plan options with you is with or contracted by a Medicare health plan or prescription
drug plan that is not the Federal Government, and they may be compensated based on your enrollment in a plan. Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan.
By providing my e-mail address or telephone number, I agree to allow Laughlin Insurance to contact me regarding information related to Medicare health plans and health insurance plans, products, services and/or educational information related to health care*

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Permission to Contact about Medicare Plans