The purpose of this form is the solicitation of insurance. Contact may be made by an insurance agent/producer. Insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. We offer plans from a number of insurance companies. By signing this form, you are agreeing to a telephone call or an email from a licensed sales agent to discuss Medicare plan options. Per The Center of Medicare and Medicaid Services (CMS) we need your permission to contact you to discuss Medicare options. By signing this form, you are agreeing to a telephone call or an email from a licensed sales agent to discuss Medicare plan options.