Medicare Made Simple - HRBC Insurance

Name
First Last
Phone*
Date*
Date Format: MM slash DD slash YYYY
Time*

: HH

MM
What would you like to discuss?*
- Stand-alone Medicare Prescription Drug Plans (Part D)
- Medicare Advantage Plans (Part C)
- Medicare Supplement (Medigap) Products
- Other (Explain Below)
Message
Your Rights*
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By clicking submit on this form, you agree to having a sales agent call to discuss the types of products you selected above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. HRBC works with various Medicare health plans. Each one has a Medicare contract. Enrollment in a Plan depends on their contract renewal. This individual may also be paid based on your enrollment in a plan. Submitting this form does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan. Material ID# H0838_1082.SOAOnline.190506_C.