Please Place Your Initial In All Medicare Products Your Intersted In
Medicare Advantage Plan ( Part C )
Please Initial Only!
Stand-Alone Presciption Drug Plans ( Part D )
Please Initial Only!
Traditional Medicare Supplment Plans ( Plans A, B, C, D, F, G, K, L, M, and N )
Please Initial Only!
Method of Initial Contact and Any Requested Appointments
Initial Method Of Contact With Agent
*
Walk-in, Call-in , Meet at a event, Requested a Scheduled Meeting
Request Date of Appontment
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
SOA must be completed 48 Hrs before Scheduled Appointment
Client Information
Named Insured
*
Physical Mailing Address
*
Street Number,Street Name,City,State and Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date Of Birth
*
Your Medicare Information
Medicare Number
*
Medicare Part A - Effective Date
*
Medicare Part B - Effective Date
*
Current Medicare Supplement / Advantage Plan
*
Your Doctors & Healthcare Information
Primary Care Physician's Name
*
Genral Practitioner - Primary Care Doctor
Primary Care Physician's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Physician's Name
*
Primary Care Physician's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name Of Preferred Pharmacy
*
Prescribed Maintenance Medication #1
Medication Name , Dosage / Strength and Frequency
Prescribed Maintenance Medication #2
Medication Name , Dosage / Strength and Frequency
Prescribed Maintenance Medication #3
Medication Name , Dosage / Strength and Frequency
Prescribed Maintenance Medication #4
Medication Name , Dosage / Strength and Frequency
Prescribed Maintenance Medication #5
Medication Name , Dosage / Strength and Frequency
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By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Please note, the person 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. Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.
Primary Insureds Signature and Signature Date:
Signature:
Signature Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Should be Empty: