WE ARE COVID-19 READY AND HERE TO HELP YOU . . . DOING BUSINESS IN THE WAY THAT YOU ARE MOST COMFORTABLE AND SAFE!

How to Get Started

To request your Medicare Planning Options Analysis, please complete the 3-step form on this page. Please be advised if you leave the page before finishing the final step, your progress will not be saved.
If you would prefer to download fillable forms click here.

AEP

Annual Enrollment Period Personal Information Sheet

Please complete and submit the form below. If you would prefer to download a fillable form, click here.

    Complete the Following:
    Agent Name:
    Client Name:
    DOB:
    Phone:
    Address:
    City:
    County:
    State:
    ZIP:
    Email:
    Tobacco Use Last 12 Months?
    Are you a current client?
    If not, how did you hear about us?
     
     
    IMPORTANT: Have you reviewed and updated your prescriptions on myMedicare.gov account?
    Current Pharmacy Name/Mail Order (very important)

    Fill Out This Section if you have a Medicare Supplement and Part D Prescription Drug Plan

    Medicare Supplement Company Name (on your Insurance Card)
    Type: (F/G/Other)
    Plan Name of Current Prescription Drug Coverage (on your Insurance Card)

    Fill Out This Section if you have a Medicare Advantage Plan

    Medicare Advantage Plan Name (HMO/PPO) (on your Insurance Card)
    Did your Annual Notice of Change ANOC list any changes to your medications for 2022?
    Would you like to change to a different Medicare Advantage insurance company for 2022?
    Primary Care Dr. Name:
    Phone:
    Specialist Name/Type:
    Phone:
    Specialist Name/Type:
    Phone:
    Eye Doctor:
    Phone:
    Dentist and Practice Name:
    Phone:
    Specialist Name/Type:
    Phone:
    Specialist Name/Type:
    Phone:
    Specialist Name/Type:
    Phone:
    Disclaimer: Sharing this information with us is strictly voluntary. The information is used to create a more accurate plan analysis based on your specific needs as presented by Medicare’s Official Website.