Contact a Licensed Agent Form

This is a solicitation of insurance. By submitting this form, I agree to be contacted by a licensed insurance agent for the marketing of the insurance products (i.e., Medicare Advantage Plans (Part C), Prescription Drug Plans (Part D), and/or Medicare Supplement (Medigap) Products) and services listed above. I’m aware the person who will discuss the products is a licensed and certified representative of Medicare Advantage organizations and/or stand-alone Prescription Drug Plans. Each of the organizations they represent has a Medicare contract. This individual may also be paid based on my enrollment in a plan. Enrollment in any plan depends on contract renewal. I am aware that the person who will contact me is not affiliated with and does not work for the Federal government.

The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any individual, one-on-one, sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

By submitting this form, I agree to a meeting with a licensed insurance agent to discuss the types of products I selected above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.

By clicking the Submit button, I (or the authorized representative) expressly consent by electronic signature to receive communications via telephone, email, text messaging, from this website or an affiliated licensed insurance agent at the contact information provided above (even if my number is currently listed on any state, federal, local, or corporate Do Not Call list). Carrier data use charges and rates may apply. I understand that my consent is voluntary and is not a condition of purchasing any goods or services, and that I may change my preferences at any time. Additionally, my (or the authorized representative’s) electronic signature also captures my consent to discuss the types of products I selected above with a licensed insurance agent.