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What is your Date of Birth

Are you currently on Medicaid? *

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No

Are you currently on Medicare? *

Yes, I have Medicare Part A ONLY

Yes, I have Medicare Part B ONLY

Yes, I have both Medicare Parts A and B

No, I do not have Medicare

Step 3 of 3

First Name

Last Name

Phone *

Email *

State

Postal code

By checking this box, I acknowledge that before meeting, Medicare requires Licensed Sales Representatives to use this form to ensure our discussion focuses only on the products I am interested in. I agree to meet with a Licensed Sales Representative to discuss Medicare-related products, including Medicare Advantage, Medicare Supplement Insurance, and Prescription Drug Plans. The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on my enrollment but does NOT work directly for the federal government. Signing this form does NOT affect my current or future Medicare enrollment, enroll me in a plan, or obligate me in any way. All information provided is confidential. I also consent to receive automated and personalized marketing text messages (e.g., appointment reminders) from Legacy Peace Of Mind at the number I provided. Messages may be sent manually or by automation. Consent is not a condition of purchase. Msg & data rates may apply. We will NEVER sell your data. Reply STOP to opt out anytime.

Full Name

By typing your full name here, you agree that you are the Beneficiary or Authorized Representative inquiring about Medicare products. A separate form should be used for each beneficiary.