By submitting this form, you are giving permission to discuss Medicare Advantage (Part C), Medicare Prescription Drug Plans (Part D), and/or Medicare Supplement (Medigap) Insurance with a licensed insurance agent. This form does not obligate you to enroll in a plan. It simply allows a licensed agent to contact you and provide information about the types of plans you are interested in.

Please Note:

• You can change your mind at any time.
• This form is valid for one appointment and expires after the meeting is complete.
• No plan information will be shared unless this form is signed and submitted.