Cheryl Austin-Chaney Health Insurance Solutions
Independent Licensed Health Insurance Broker | CA License # 4557256
STATEMENT OF APPOINTMENT (SOA)
1. BENEFICIARY INFORMATION
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
2. APPOINTMENT INFORMATION
Appointment Type (Check One):
In Person
Telephone
Video Conference
Date of Appointment:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time:
Hour Minutes
AM
PM
AM/PM Option
3. PRODUCTS TO BE DISCUSSED
I understand that during this appointment, the following Medicare-related products may be discussed.
Medicare-related products
Medicare Supplement (Medigap)
Medicare Advantage Plans (Part C)
Prescription Drug Plans (Part D)
Dental
Vision
Hearing
Hospital Indemnity
Cancer Insurance
Critical Illness Insurance
Accident Insurance
Other
4. BENEFICIARY ACKNOWLEDGMENT
By signing below, I requesting this appointment and understand that no obligation exists to enroll in any plan.
I also understand that only the products selected above will be discussed during this appointment unless I request otherwise.
Beneficiary Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
5. AGENT INFORMATION
Cheryl Austin-Chaney
Independent Licensed Health Insurance Broker
California License #4557256
Phone:
(951) 410-8448
Email:
info@cachealthinsurance.com
Date Acknowledged
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Not connected with or endorsed by the U.S. government or the federal Medicare program.
Medicare has neither reviewed nor endorsed this information.
For more information about Medicare, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).
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