Items of Interest Response Form October 12, 2017October 12, 2017 Lance Uncategorized Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone *Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Spouse's NameSpouse's Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EmailAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNote: If you would like us to shop for a prescription drug plan for you, please use our PDP Helper page and submit a list of your prescriptions to us there. Medicare SupplementsI’m turning 65. Please contact me concerning a Medicare SupplementMy Medicare supplement rates have gone up.Name of your current company: *Note: If you have a health condition and are not sure if you will qualify, please contact us anyway.Plan:(indicate lettered plan A-N)Monthly Premium:I have a Medicare Advantage plan and I’m interested in returning to original Medicare, and I want to see if I qualify for a Medicare supplement. Part D Prescription Drug Plans (PDP):I still need to be signed up for a Medicare Prescription Drug Plan.I’m shopping for a new PDP.Please visit our PDP Helper page and use that form instead to submit a list of your prescriptions to us. Medicare Advantage and Prescription Drug Plan (MA-PD)I’m interested in an MA-PD plan.Note: Enrolling in a new MA-PD will disenroll you from your existing PDP or MA-PD plan. I have a non-renewed Medicare Advantage PlanI’m interested in switching to a Medicare supplement on a guarantee issue basis, plan A, B, C, F, K, or L.I’m interested in another MA-PD plan.Name of your current non-renewed MA plan: * OtherBurial insuranceLong or short-term care insuranceAnnuitiesAny other Comments?PhoneSubmit