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Medicare Reviews

Know Your Options

The local, licensed Insurance Agents at Claybar Insurance Company specialize in Medicare Insurance products.

We can explain your health care options including:

Please Contact Me About Medicare Plans

Contact Us

Full Name

Address

Address Line 2

City

State

Zip

Phone

Medicare Eligible

YES

Check if Applicable

I am not eligible to enroll before October 15th, please contact me between October 1 and December 7

I am interested in plan information for the following (check all that apply): (plan availability may vary by location)

Prescription Drug Plans

Medicare Supplement Plans

Medicare Advantage Plans

Dental Plans

Hospital Indemnity Plans

By providing my email address or telephone number, I agree to allow a licensed sales representative to contact me regarding information related to Medicare health plans and health insurance plans, products, services, and/or educational information related to Medicare health plans and health insurance plans, products, services, and/or educational information related to health care.

I AGREE

ELECTRONIC SIGNATURE

Date

According to Medicare rules, we need your permission to contact you to discuss your Medicare plan options. By accepting this form, you are agreeing to a sales telephone call or an email from a licensed sales agent to discuss the specific types of products above. The person who will be discussing plan options with you is with or contracted by a Medicare health plan or prescription drug plan that is not the Federal Government, and they may be compensated based on your enrollment in a plan. Signing this does NOT affect your current enrolment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan.

I UNDERSTAND

SCOPE OF APPOINTMENT FORM

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Medicare Reviews

Know Your Options