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Have Questions About Medicare, Health, or Life Insurance?

Submit the form below to speak with a licensed advisor who can help you understand your options.

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Do you currently have health insurance? *

Are you looking to get Medicare coverage? *

Which best describes your situation? *

Please check the box(es) for the products you would like to discuss. This is called a Scope of Appointment. Please note: Only the products selected may be discussed during your appointment. If you wish to discuss additional products, a new Scope of Appointment will be required. *

Medicare Advantage (Part C)

Medicare Advantage with Drug Coverage (Parts C&D)

Prescription Drug Plans (Part D)

Medicare Supplement (Medigap) Plans

Dental, Vision, and Hearing Plans

Hospital Indemnity or Other Supplemental Plans

By Signing below, I understand that the boxes checked above are the only products that I wish to discuss at our appointment and that a licensed agent (Cassie Patterson) may be contacting me at the contact information I provided on this form. *

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By checking this box, I consent to receive non-marketing text messages from Cassie Patterson about plan options, plan maintenance, and general communications pertaining to my health insurance. This consent is NOT required to receive services. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, product updates, and insurance information from Cassie Patterson at the phone number provided. We will not spam you, but there are times when marketing messages are necessary. This consent is NOT required to receive services. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Consent to receive communications is not a condition of purchasing insurance.

Important Information

Submitting this form does not constitute an application for insurance and does not affect your eligibility for coverage. A licensed insurance agent may contact you by phone, text message, or email to verify information and discuss available insurance options.

This is a consent to be contacted and a solicitation for insurance. If Medicare products are selected, a Scope of Appointment will be recorded prior to discussing plan details as required by the Centers for Medicare & Medicaid Services. Information you provide is protected under the Insurance Information and Privacy Protection Act (IIPPA) and HIPAA. For more information about your rights and how we protect your information, please see our Privacy Policy here.

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