COLLOCAMOTION Consent to Contact 
By voluntarily providing my contact information, I authorize COLLOCAMOTION Financial & Wellness, LLC's Licensed Health Insurance agents, associates and/or staff to contact me now or during the next Open Enrollment Period when new benefit information is available.

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Email *
Last Name
First Name
Phone number
Home State
Ex ( FL, TX, CA, NY, NJ, NC, SC )
Zip code
County
Preferred Languages
ex.English, Spanish
Benefit Advisor/Broker/Agent Name if known, or just first available*


Please choose the Health Insurance related topic that do you need help with
Please note that non-health related insurance plans cannot be discussed at the same time of Medicare Advantage plans. Non-health related meetings can be scheduled at a later time.
Please choose other topics that you need help with
Please note that non-health related insurance plans cannot be discussed at the same time of Medicare Advantage plans.  

Disclaimer: This is a solicitation of insurance. Agent is a licensed and certified representative of multiple Medicare Advantage and Prescription Drug plans each with a Medicare contract. Enrollment depends on contract renewal. Contact may be made by an insurance agent or insurance company. Not affiliated with or endorsed by any government entity or agency. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY: 1-877-486-2048), 24 hours a day, 7 days a week, to get information on all your options. CF577 2/2023 

By completing this form you authorize a  COLLOCAMOTION Financial & Wellness  LLC  agent to contact you now or during the next open enrollment period when new benefit information is available.

COLLOCAMOTION Financial & Wellness  LLC is a licensed company that is appointed, certified and trained to represent multiple insurance plan options that include but are not limited to Medicare supplements, Medicare Advantage plans, Life, Retirement Health and stand-alone prescription drug plans. 

Please let us know of any specific questions in the  notes section 

NOTES:
Best day of the week
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Best Time for one of our agents to contact you
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By providing my contact information, I agree to be contacted by a licensed insurance agent.

Please type in your name to agree.
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A copy of your responses will be emailed to the address you provided.
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