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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.

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