Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I understand that I am requesting a meeting with an independent insurance agent at Coveside Healthcare Coverage Options who has a contract with Aetna, Anthem, Humana, Martin’s Point Generations Advantage, and UnitedHealthcare, and to offer their Medicare plans. *

Yes

No

I understand that the representative will be discussing Standalone Medicare Prescription Drug Plans, Medicare Advantage plans, and other Medicare-related products, such as Medicare Supplement plans or Dental, Hearing, Vision. *

Yes

No

I understand that the person who will be discussing these plans are contracted by private companies who have a Medicare contract to offer Medicare Advantage, Medicare Prescription Drug, and Medicare Supplement plans. *

Yes

No

I understand that if I agree to this appointment, there is no obligation to enroll, current or future Medicare enrollment status will not be impacted, nor will it automatically enroll me in a Medicare Advantage Plan, Stand-alone Prescription Drug Plan, or other Medicare-related product. *

Yes

No

I understand I am not required to provide any health-related information to our insurance agents unless it will be used to determine enrollment eligibility. *

Yes

No

Date *

MM

DD

YYYY