Annual Enrollment Original Medicare What is needed for Annual Enrollment Original Medicare? Yearly update on your Medicare coverage and options Supports decision-making during open enrollment Allows listing of prescriptions and special doctor requirements Lets you indicate interest in reviewing or changing plans Safeguards all data, using it only to refine your coverage recommendations Annual Enrollment Original Medicare Notify Personal InformationTell us who needs coverage so we can match you with the right plans.First NameLast NameEmailPhone NumberZip CodeCountyMailing address different from residential address? Yes NoMailing AddressDate of BirthTobacco User? Yes NoCurrent Coverage InformationWhat are your thoughts regarding your current coverage for medicare supplement? I am happy with my medicare supplement I’d like to review other medicare supplement options I’d like to review Medicare advantage optionsDo you live with someone else in the household? Yes NoWould you like quotes using an EFT discount, or do you prefer check or debit/credit card payment? EFT (discount may apply with this option) Mail in a check, credit or debit cardPlease provide all doctors that need to be in-networkPharmacyPreferred pharmacyPrescription InformationPlease list any prescriptions you are taking that you want to make sure are covered — names, doses and frequencies I agree to the Terms and Conditions and Privacy Policy. Submit Questionnaire
