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Items of Interest Response Form

October 12, 2017October 12, 2017 Lance Uncategorized

Name *

First

Last

Phone *

Date of Birth//

Spouse's Name

Spouse's Date of Birth//

Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Note: If you would like us to shop for a prescription drug plan for you, please use our PDP Helper page and submit a list of your prescriptions to us there.

Medicare Supplements

I’m turning 65. Please contact me concerning a Medicare Supplement
My Medicare supplement rates have gone up.

Name of your current company: *

Note: If you have a health condition and are not sure if you will qualify, please contact us anyway.

Plan:

(indicate lettered plan A-N)

Monthly Premium:

I have a Medicare Advantage plan and I’m interested in returning to original Medicare, and I want to see if I qualify for a Medicare supplement.

Part D Prescription Drug Plans (PDP):

I still need to be signed up for a Medicare Prescription Drug Plan.
I’m shopping for a new PDP.

Please visit our PDP Helper page and use that form instead to submit a list of your prescriptions to us.

Medicare Advantage and Prescription Drug Plan (MA-PD)

I’m interested in an MA-PD plan.

Note: Enrolling in a new MA-PD will disenroll you from your existing PDP or MA-PD plan.

I have a non-renewed Medicare Advantage Plan

I’m interested in switching to a Medicare supplement on a guarantee issue basis, plan A, B, C, F, K, or L.
I’m interested in another MA-PD plan.

Name of your current non-renewed MA plan: *

Other

Burial insurance
Long or short-term care insurance
Annuities

Any other Comments?

Email

Post navigation

Medicare Advantage Funding and the Causes of Non-Renewal Notices

Miscellaneous Notes for November 2017

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