Scope of Appointment · Chambers Insurance Group

Scope of Appointment · Chambers Insurance Group

Select the product types you want to discuss, then complete beneficiary and appointment details before your Medicare appointment.
About You
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Medicare Number or Medicare Beneficiary Identifier
Authorized Representative
Authorized representative name
Relationship to beneficiary
The Appointment
Date of appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Appointment type
How did you first contact the agent, or how did the agent first contact you?
Agent Information
Agent name
Agent phone
Agent NPN
Agency
Plans the agent represents at this appointment
Acknowledgement and Signature
I understand that the person discussing plan options with me is either employed by or contracted with a Medicare plan and may be compensated based on my enrollment in a plan. Signing this form does not obligate me to enroll in a plan and does not affect my current or future enrollment.
Beneficiary or Authorized Representative Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: