HEY THERE!

According to Medicare rules, we need your permission to contact you to discuss your Medicare plan options. By accepting this form, you are agreeing to a sales telephone call or an email from Brian C. Moore, Certified Medicare Insurance Planner™ CMIP® (licensed sales agent) to discuss Prescription Drug Plans, Medicare Supplement Plans, or Medicare Advantage Plans whom is contracted by Medicare health plan's and prescription drug plan's that is not the Federal Government, and may be compensated based on your enrollment in a plan. Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan