Medicare Cost Evaluation

Medicare Cost Evaluation

Help us evaluate your Medicare options and see if GTLIC products can help reduce your out-of-pocket costs. This form is for evaluating ways to lower your Medicare expenses and is not intended to replace Medicare itself. YOU DO NOT NEED TO PROVIDE YOUR MEDICARE NUMBER
This form is designed to evaluate your options for reducing Medicare costs. We may recommend GTLIC products to help cover deductibles and out-of-pocket expenses. Completing this form does not replace your Medicare coverage.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
Current Medicare Coverage Type*

Original Medicare + SupplementMedicare AdvantageOther
Carrier
Advantage Plan
Current Supplement Plan Name
Current Supplement Plan Monthly Premium ($)
Prescription Drug Coverage Details (plan name, premium, etc.)
Expected Medical Usage (select all that apply)

Primary Care Doctor VisitsSpecialist VisitsHospital StaysOutpatient ProceduresEmergency Room VisitsOther
What is your monthly budget for healthcare costs, and do you have any specific cost concerns?
How may we contact you? (Select all that apply)*

PhoneEmailText Message
Should be Empty: