ITDR Focus Group Interest Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
City, State
*
Former (or Current) Delta Department and City
*
Please check the box that best describes your situation
*
Currently Enrolled in ITDR
I am not yet on Medicare
Current Delta employee
Other
Year retired, or Year you plan to retire
*
If you are on an ITDR plan, please list which plan you are on. If your spouse is on a different plan, please also check that plan.
Medicare Supplement Enhanced
Medicare Supplement Standard
Medicare Advantage Prime
Medicare Advantage Enhanced
Medicare Advantage Standard
I am interested in becoming a member of the ITDR Focus Group because:
*
Submit
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