Please select what you want to discuss with the Licensed Sales Representative. (Req'd by Medicare)

By signing this form, you agree to speak with a Licensed Sales Representative to discuss the products checked above. The Licensed Sales Representative is contracted by Medicare plans and may be paid based on your enrollment in a plan. We do not work directly for the federal government.

Beneficiary or Authorized Representative
Typed Signature and Signature Date:

Please type your full name and today's date below to confirm your authorization (Required by Medicare)
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AUTHORIZED REPRESENTATIVE INFORMATION
(IF APPLICABLE) If you are the authorized representative of the beneficiary, please sign above and enter your name and relationship below: 
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Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential.