Scope of Appointment

Step 1 of 2

In the space provided below, please check the box next to the type of health product(s) you want the licensed sales agent to discuss.

Product Selection

Medicare Advantage plans (Part C)

Stand-alone prescription drug plans (Plan D)

Medicare Supplement plans

Dental plans

Vision plans

Hospital Indemnity plans

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship to the beneficiary

Medicare ID number (optional)

Agent(Required)

By signing this form, you are agreeing to a sales meeting with a sales agent to discuss the specific types of products you initialed above. The person that will be discussing plan options with you is either employed 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 form does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage plan, prescription drug plan, or other Medicare plan.

Beneficiary or legally authorized representative signature and signature date:

Signature

Date

Contact Form

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Name*

First Last

Email*

Phone

Message*

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Scope of Appointment

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