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Medicare Consultation Form

Hi! My name is George. I am your Medicare guide!

 

Please complete this form in order for me to properly understand your current or future Medicare needs. All information gathered is confidential. If and when you enroll in a plan, we will gather your information from this form and verify it is accurate as we complete an application. Thank you!


Have questions? Call me at 859-414-6591.

Tell me about yourself
Do you have an existing Medicare Supplement or Medicare Advantage plan?
Do you have any of the preexisting conditons listed below?
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Beyond normal vacations, do you live outside your current state for more than a month at a time?

Thanks! I will call you at my earliest opportunity!

Medicare Consultation Form Disclosure

By completing this form you agree that a licensed insurance agent may contact you by phone or email to answer any questions you have regarding Medicare plans. This is a solicitation for insurance.

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