Medicare Questions

Contact me about Medicare Plans

Currently Medicare Eligible
YesNo If no, when will you be eligible:
Yes If I'm not eligible to enroll before open enrollment begins on October 15, contact me
between October 1 and December 7

By giving my contact information, I agree to allow a licensed sales representative to contact me about information related to Medicare options or to enroll in a plan.

Interested in plan information for

Prescription drug plansSupplement plansMedicare advantage plansAncillary products (i.e. dental, vision, hearing, cancer, hospital indemnity)

(plan availability may vary by location)

By giving my contact information, I agree to allow a licensed sales representative to contact me about information related to Medicare options or to enroll in a plan.

Signature: Date:

I understand that the person who will be discussing plan options with me may be compensated based on my enrollment plan.