Forms 2018-01-25T20:40:06+00:00

Take the first step towards better health and life insurance today.

Choose the correct form from below and fill out each option to the best of your knowledge.

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  • Medicare Plan Quote Sheet

  • Where do you live?
  • Add a row

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  • Medicare Part D Worksheet

  • Drug NameDosageFrequencyDrug Type 
    Add a row

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    Refer to the product descriptions below if you aren't sure which to choose.
  • 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.

  • Beneficiary or Authorized Representative Signature and Signature Date:
  • If you are the authorized representative, please sign above and print clearly and legibly below:

Complete the form below or, print a copy to fill out by hand.

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