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Medicare FactFinder

Would you like your Medicare Plan Comparison Report delivered by Email or USPS?
Scope of Appointment Confirmation. Select the product(s) you wish to discuss. Check all that apply.
Medicare Status
Are you, or do you anticipate, receiving any of these benefits? Check any that apply.
Do you have an family member, friend or Authorized Representative that helps you make important decision?
Do you receive a Health Insurance Subsidy that reduces the cost of Medicare? If so, how much annually?
What is your most important Medicare planning goal?
Medical History
Do you smoke?
What Value-Added Benefits do you need?
Have you been diagnosed with any of these conditions (check all that apply):
Describe your general health status?
Healthcare Provider
Prescription Medications
How do you prefer to be contacted by your Benefit Advisor, Cell phone, Text or Email?
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