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Health declaration

Please fill out the following form.

Date of birth
Have you been hospitalized in the last 12 months?
No
Yes
Are you suffering from a medical condition, illness or injury?
No
Yes

2024 Required Medicare Disclaimer: “We do not offer every Medicare Advantage plan available in your area. Currently we represent 5 organizations which offer 43 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.” (plan availability may vary by county in which you reside)

 

2024 Required Medicare Disclaimer: “We do not offer every Medicare Part D (Rx) plan available in your area. Currently we represent 5 organizations which offer 9 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.”

Not affiliated or endorsed by the Government or Federal Medicare Program.

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