Medicare

Name:		email:
Home Phone:		Day Time Phone:
Address:		City:
State:		Zip Code :
Who is this quote for?	Self Spouse Others (check all that apply) If also for Spouse NAME:
Applicant Birth Date: Spouse Birth Date:
Please just Call me and let me know if I qualify for one of the FREE MA Plans to cover the 20% gap. Yes No

Brief Survey to determine enrollment: Are you just turning 65? Yes No
Do you take any medication? Yes No If over 65 : ( This is if it is not open enrollment Nov. 15-Dec 31. Do you have high cholesterol Yes No Do you have High Blood Pressure Yes No Have you recently moved Yes No Are you on Medical Yes No Are You on Medicaid Yes No Are You Just discontinuing work Insurance Yes No
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