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Don't Forget...
Before we can review your plan options with you, you need you to fill out this onboarding form...
Onboarding Form:
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1
Prospect Info
2
Prescription Drug info
3
Provider Info
4
Permission Info
Name
*
First
Last
Address
*
Address Line 1
City
State / Province / Region
Postal Code
Phone
*
Email
*
Date of birth
*
Current Medicare Plan Name and Company
*
Please look at the card your current company issued you and note down the details including the plan ID number. Example 1: Wellcare Dividend Giveback (HMO) 2024-H5475-032-000 Example 2: Medicare Supplement plan G through Aetna
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Prescription Drugs
Please list your prescription drugs if you'd like your plan to get them at the lowest possible cost.
What is a prescription medication you take?
Example: Metformin 20mg 3x a day 90 day supply through CVS
What is a prescription medication you take?
Example: Metformin 20mg 3x a day 90 day supply through CVS
What is a prescription medication you take?
Example: Metformin 20mg 3x a day 90 day supply through CVS
What is a prescription medication you take?
Example: Metformin 20mg 3x a day 90 day supply through CVS
What is a prescription medication you take?
Example: Metformin 20mg 3x a day 90 day supply through CVS
What is a prescription medication you take?
Example: Metformin 20mg 3x a day 90 day supply through CVS
Please input additional prescription drugs if needed
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Doctors & Specialist
Please list your doctors and specialists if you'd like your plan to accept them.
Who is your general physician?
Example: Dr. Matt Smith 12345 Center Ridge Rd. Suite 101 Coffeyville KS 67337, (620)111-1111
Who is a specialist you see?
Example: Dr. Matt Smith 12345 Center Ridge Rd. Suite 101 Coffeyville KS 67337, (620)111-1111
Who is a specialist you see?
Example: Dr. Matt Smith 12345 Center Ridge Rd. Suite 101 Coffeyville KS 67337, (620)111-1111
Who is a specialist you see?
Example: Dr. Matt Smith 12345 Center Ridge Rd. Suite 101 Coffeyville KS 67337, (620)111-1111
Who is a specialist you see?
Example: Dr. Matt Smith 12345 Center Ridge Rd. Suite 101 Coffeyville KS 67337, (620)111-1111
Please input additional doctors or specialists if needed (copy)
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Scope of Sales Appointment Confirmation Form
The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any individual 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. Scope of Appointment documentation is subject to CMS record retention requirements
Plan Options You Would Like to Discuss (Check all that apply)
*
Medicare Supplement Plans
Medicare Advantage Plans (HMO & PPO)
Prescription Drug Plans
Dental, Vision & Hearing Plans
Hospital Indemnity Plans
Please check the box beside the type of product(s) you want the agent to discuss.
Signature
*
Clear Signature
By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed 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. Signing this form does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan.
Today's Date
*
Disclaimer
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE or your local state health insurance partnership to get information on all your options. But because we are an independent agency, we only compare the most competitive companies in any given areas.
Plan Definitions:
Medicare Supplement Plans
Plans offering a supplemental policy to fill “gaps” in Original Medicare coverage. A Medigap policy typically pays some or all of the deductible and coinsurance amounts applicable to Medicare-covered services, and sometimes covers items and services that are not covered by Medicare, such as care outside of the country. These plans are not affiliated or connected to Medicare.
Medicare Advantage HMO Plans (Part C)
Medicare Health Maintenance Organization (HMO): A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).
Medicare Advantage PPO Plans (Part C)
Medicare Preferred Provider Organization (PPO) Plan: A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.
Stand-alone Medicare Prescription Drug Plans (Part D)
A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.
Hospital Indemnity Plans
Plans offering additional benefits; payable to consumers based upon their medical utilization; sometimes used to defray copays/coinsurance. These plans are not affiliated or connected to Medicare.
Dental, Vision, and/or Hearing Plans
Plans offering additional benefits for consumers who are looking to cover needs for dental, vision or hearing. These plans are not affiliated or connected to Medicare.
SUBMIT ONBOARDING FORM NOW
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What type of insurance do you want a quote for?
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Medicare Supplement
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Drug Plans
Dental & Vision
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Information needed
Zipcode
*
Age
*
Is this information for you or you and a spouse?
*
Just me
Me and a spouse
Do you use tobacco?
*
Yes
No
Current Medicare Supplement plan
Plan F
Plan G
Plan N
Interested In
*
Dental Insurance
Vision Insurance
Hearing Insurance
Next
Where do you want the quotes sent to?
Email address
*
Email Quotes
Last info we need
Name
*
First
Last
Phone Number
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You agree to receive communications in accordance with TCPA regulations
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I do
Custom Captcha
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What type of insurance do you want a quote for?
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Annuities
Critical Illness Insurance
LTC Insurance
Life Insurance
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Information needed
Zipcode
*
Age
*
Is this information for you or you and a spouse?
*
Just me
Me and a spouse
Next
Information needed
Do you use tobacco?
*
Yes
No
Beneficiary Name
*
First
Last
Benefit Amount
*
Under $25,000
Under $25,000
$25k-$50k
$50k-$250k
$250k-$500k
$500k+
Amount of Assets to Insure
*
Less than 250k
250k-500k
500k-1M
1M+
Interest In
*
Income Now
Income Later
Growth Without Risk
Interested In
*
Cancer Insurance
Heart Attack/Stroke Insurance
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Where do you want the quotes sent to?
Email address
*
Email Quotes
Last info we need
Name
*
First
Last
Phone Number
*
You agree to receive communications in accordance with TCPA regulations
*
I do
Custom Captcha
*
What is 7+4?
Get Quote Now
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 4
What type of insurance do you want a quote for?
*
Medicare Supplement
Medicare Advantage
Drug Plans
Dental & Vision
Next
Information needed
Zipcode
*
Age
*
Is this information for you or you and a spouse?
*
Just me
Me and a spouse
Do you use tobacco?
*
Yes
No
Current Medicare Supplement plan
Plan F
Plan G
Plan N
Interested In
*
Dental Insurance
Vision Insurance
Hearing Insurance
Next
Where do you want the quotes sent to?
Email address
*
Email Quotes
Last info we need
Name
*
First
Last
Phone Number
*
You agree to receive communications in accordance with TCPA regulations
*
I do
Custom Captcha
*
What is 7+4?
Get Quote Now