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Medicare Required Scope of Appointment

Please select all topics you would like to learn about or discuss. Medicare requires this information in advance.

Signing up for Medicare Part A and Part BMedicare Supplement (Medigap) plansMedicare Supplement quotesMedicare Advantage plansMedicare Part D prescription drug plansAncillary benefits (dental, vision, hearing, hospital indemnity, cancer / critical illness, etc.)Annuities or long-term care planningLife insurance optionsOther

I understand there is no obligation to enroll in any plan. My current or future Medicare coverage will not be impacted, and no automatic enrollments will occur.

I understand the agent does not work directly for the Federal government and may be compensated for any enrollment.

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This form is not to be used as a means of soliciting me for some service/offer/product that you have!

When you contact me, you will be contacting a licensed insurance agent in the state of Arizona, California, Florida, Georgia, Illinois, Maryland, Michigan, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Washington.

CALLING/CONTACT AGREEMENT: You agree that by clicking the “SUBMIT” button below you consent and request that I, and those acting on my behalf, may call, text or e-mail you. Calls can be made to any number you provide above even if listed on a national or state Do Not Call registry. You are agreeing to be contacted by a Licensed Sales Agent by email or phone call to discuss information about Medicare Insurance Plans. This a solicitation for insurance. Your information will be provided to me, a licensed agent for future contact.

MOST IMPORTANTLY: I do not sell, give away, or provide your personal contact info to anyone else. The only other person that may contact you would be an assistant working for me.