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 By submitting this form you agree that a licensed insurance agent employed with e-TeleQuote Insurance, Inc., may contact you regarding health and life insurance products and services including Medicare Advantage, Medicare Advantage with a Prescription Drug plan, Medicare Supplement and Prescription Drug plans or Life Insurance plans by phone, text message or email. You expressly consent to receive phone calls (including autodialed and/or pre-recorded calls) text messages and email using automated technology at the phone number and email address you provided, even if it is a wireless number, regardless of whether you are on any Federal or state DNC ("Do Not Call") and/or DNE ("Do Not Email") list or registry. In addition, you understand and acknowledge that data and message rates may apply. Furthermore, you acknowledge that you are over 18 years of age.

Online quotes may not be available for all Medicare Advantage, Medicare Supplement and Prescription Drug plans, but the agency that will be discussing these plan options with you is contracted with various Medicare health or prescription drug plans, which may include Medicare Advantage and/or Prescription Drug plans under the Federal government Medicare program and/or Medicare Supplement plans that are not under the Federal government Medicare program. The licensed agent may be compensated based on your enrollment in such a plan. Medicare Supplement plans are not connected with or endorsed by the U.S. Government or the Federal Medicare program. Submitting this form does NOT affect your current Medicare Part A and Part B enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan.

Receiving quotes through our website and from our licensed insurance agents is always free and you are under no obligation to purchase any goods or services as a result of this request. You agree that we may share your information with third parties, and you may receive surveys of service, account updates or other special offers via email, phone or text message sent by e-TeleQuote Insurance, Inc. and/or our partners. You may revoke your express consent at any time by contacting us via 1-877-336-1489 or email at opt.out@e-telequote.com so that you may be placed on our do-not-call and/or our do-not-email list.