Please Contact me about Medicare Plans

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Permission to Contact Form

Name *

Address *

Email *

Phone number *

Are you Medicare Eligible? *

Yes

I am not eligible to enroll before October 15th, please get in touch with me between October 1st and December 7th. *

Please Contact me during the Annual Enrollment Period

I'm Eligible to enroll now

By providing my email address or telephone number, I agree to allow a licensed sales representative to contact me regarding information related to Medicare health plans and health insurance plans, products, services, and/or educational information related to healthcare *

I Agree

Required

Would you prefer a text message? *

Yes

I am interested in plan information for the following (check all that apply) *plan availability may vary by location* *

Prescription Drug Plans

Medicare Supplement Plans

Medicare Advantage Plans

Dental Plans

Hospital Indemnity Plans

Required

Sign and Date *

According to Medicare rules, we need your permission to contact you to discuss your Medicare plan options. By accepting this form, you are agreeing to a sales telephone call or an email from a licensed sales agent to discuss the specific types of products above. The person who will be discussing plan options with you is with or contracted by a Medicare Health Plan or prescription drug plan that is not the Federal government, and they may be compensated based on your enrollment in a plan. Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare Plan. *

You have permission to contact me

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