Insurance quote thank you page

Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that the Licensed Sales Representatives use this form to ensure your appointment focuses only on the type of plan and products you are interested in.

Please check what you want to discuss with the Licensed Sales Representative. *

Medicare Advantage Plans (Part C) and Cost Plans

Stand-alone Medicare Prescription Drug Plan (Part D)

Medicare Supplement (Medigap) Plan

Dental-Vision-Hearing Products

Hospital Indemnity Products

By signing this form, you agree to meet with a Licensed Sales Representative to discuss the products checked above. The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They DO NOT work directly for the federal government.

Signing this form DOES NOT affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan, or obligate you to enroll in a Medicare plan. All information provided on this form is confidential.

Last Name *

First Name *

Beneficiary or Authorized Representative Signature: *

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Signature Date *