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Gender
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Spouse's Information
Spouse's Name
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Medicare Information
Requested Effective Date
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What Plan Are You Interested In?
Select
Medicare Advantage Plan
Medigap (Supplemental)
Other
Not Sure
Do You Currently Have an Advantage or Supplemental Plan?
Yes
No
I Am Newly Eligible for Medicare:
Yes
No
Are You Covered Under Medicare "Part A" & "Part B" ?
Yes
No
If "No" When Are You Eligible?
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Is Your Spouse Covered Under Medicare "Part A" & "Part B" ?
Yes
No
If "No" When Is He or She Eligible?
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I Am Interested In Medicare Prescription Drug (RX) Plan?
Yes
No
I Am Interested In Dental Plan?
Yes
No
What Can I do to Earn Your Business?
Do You Have Any Questions or Suggestions or Current Health Conditions?