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Group Health or Individual & Family Plan
*
Group Health
Individual & Family Plan
Medicare
Company Name
*
Your Name
*
Date of Birth (Needed for Accurate Quote)
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Phone
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Email
*
Next
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Maine
Maryland
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Texas
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State
Zip Code
Is Mailing Address the Same as Business Address
Yes
No
Mailing Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Nevada
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New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Next
Desired Effective Date of Policy
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Are you Currently Insured
*
Yes
No
Current Insurance Carrier
Type of Medicare Product
Medicare Supplement (Plan G, N, F)
Medicare Part D (Prescription Drug Coverage)
Medicare Advantage Plan (HMO)
Have you Enrolled into Medicare Part A
*
Yes
No
Part A Enrollment Effective Date
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Have you Enrolled into Medicare Part B
*
Yes
No
Part B Enrollment Effective Date
*
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Business Type
Corporation Type
*
Individual / Sole Proprietor
Limited Liability Corp (LLC)
S-Corp
C-Corp
Partnership
FEIN Number
Number of Individuals to be Included In Plan
*
1
2
3
4
5
6 or More
Number of Full Time Employees
Number of Part Time Employees
Name
Submit
99496
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