Medicare & Health Care Cost Evaluation

Medicare & Health Care Cost Evaluation

Help us evaluate your Medicare & Health options and see if GTLIC products can help reduce your out-of-pocket costs. This form is for evaluating ways to lower your Medicare or Health Care 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 or Health Care 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

Other
Carrier
Type of Plan
Current Supplement Plan Name
Current Monthly Cost ($)
Prescription Drug Coverage Details (plan name, premium, etc.)
Expected Medical Usage (select all that apply)

Other
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)
Should be Empty: