First Name *

Last Name *

Phone *

Email *

Main Applicant Date of Birth *

Gender *

Please use the Search Bar below to find your mailing address so we can send your cards.

Address *

Street Address *

City *

State *

Postal Code *

County *

Do you currently have a Medicare Advantage plan? *

Yes

No

Do you currently have any other health or drug coverage besides Medicare or Medicaid? (e.g., VA, TRICARE, employer coverage) *

Yes

No

Have you been diagnosed with any chronic condition (like diabetes, heart disease, or kidney failure)? *

Yes

No

Medication Name

Dosage

Please write only in MG e.g., 0.5 or 10

Refill Frequency

Quantity

Doctor's City

Your Medicare Claim Number is required to verify your eligibility and enroll you in the best plan for your needs. This number is only used by licensed agents and is protected under federal privacy laws. If you don't have your card handy, you may provide it securely to the agent after completing this form.

I allow my Agent to find my MBI using my SSN

I Agree

Social Security Number *

Do you currently have your Medicare claim ID number available with you right now?

By signing below, I confirm that I am providing a Scope of Appointment for a licensed insurance agent to discuss the following Medicare-related topics with me: *

Medicare Advantage with Part D (MAPD)

Prescription Drug Plan (PDP)

Medigap Plans

Medicare Advantage (MA)

Scope of Appointment *

Clear

Invalid signatures (dots, marks, etc.) may result in application denial. Please provide a clear, valid signature.

Application and benefits signature *

Clear

Invalid signatures (dots, marks, etc.) may result in application denial. Please provide a clear, valid signature.

Eligible Plans: