Client Registration Form

Senior Planning Today and Tomorrow

We’ve helped thousands of people in Alabama, Arkansas, Louisiana, Mississippi, and Tennessee over the years— helped them navigate the insurance maze. We have found lower cost coverage options; helped them reduce their premiums and increase their benefits; helped them avoid the catastrophic costs associated with major diseases, major surgery, home healthcare, and nursing homes. We have helped many transition into Medicare and insurance products designed to work with Medicare. Let us help you, too!

Call or stop by to connect with one of our licensed Insurance Agents:

    Getting started is easy. We will have one of our licensed agents contact you and walk you through every step of the process.

    By providing the information above I grant permission for a licensed insurance agent to call or email me regarding my Medicare options including. Medicare Supplement, Medicare Advantage and Prescription Drug Plans.

    Year End Survey Prescription Questionnaire

      Full Name*

      DOB

      Home Phone

      Cell Phone*

      Email*

      Mailing Address

      Physical Address:(if different)

      County

      What company provides your. Medicare Supplement Insurance?

      What is your premium?

      Plan Letter (look on your card):

      Would you like us to evaluate your current plan pricing compared to another plan?

      Are you interested in a Medicare Advantage plan?

      What company provides your Medicare Advantage Plan?

      What plan do you currently have?

      Please list Name of your Primary Care Physician.

      List any other Physicians you see and preferred Hospital.

      What company provides you with Prescription Drug Insurance?

      What is the name of your plan (as shown on your ID card)?

      What is the premium in 2023?

      How do you want to pay the premium? (Circle one) (SS deduction, bank draft, or invoice/coupon book)?

      Preferred pharmacy or mail order service?

      What is the name of your plan (as shown on your ID card)?

      Please provide comments and questions here:

      Please provide comments and questions here:

      price-1

      Drug Name

      Capsule or Tablet

      Brand or Generic

      Dosage

      Quantity

      How often do you fill

      Price