FILL OUT THE FORM BELOW

We require your consent before contacting you to go over your Medicare plan alternatives, given Medicare regulations. By filling the form below, you consent to a licensed sales representative contacting you by mail, phone or email to discuss particular products. The person who will talk to you about your plan alternatives works for or is employed by a Medicare health plan or a prescription drug plan that is not a Federally-sponsored program, and they might receive payment based on your participation in a plan. Your current enrollment in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan will not be impacted by signing this form, nor will it enroll you in one.

By providing my telephone number or email address, I agree that a licensed insurance representative may contact me by phone, SMS, or email to discuss my Medicare alternatives, including Medicare Supplement, Medicare Advantage, and Prescription Drug Plans.