User Survey - Legacy Insurance

Did you know? Medicare was signed into law by LBJ in ‘65.
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- Step 1 of 9
What’s Your Name?

Name
First
Last
What’s Your Email?

Email
What’s Your Address?

Name Physicians Enter

Address
Address Line 1
Address Line 2
City
State
Zip Code
What’s Your Phone?

Phone
What’s Your Preferred Pharmacy?

What’s Your Preferred Hospital?

Who Are Your Physicians?

Enter Physicians Name
What Prescriptions Do You Take?

Enter Prescriptions Below
Scope Of Sales Appointment Confirmation Form

Signature

Clear Signature

By providing the information in this form, you are granting permission for a licensed insurance agent to contact you via phone, text, or email regarding your Medicare options including Medicare Supplement, Medicare Advantage, and Prescription Drug Plans. Providing permission does not impact eligibility to enroll or the provision of services.

Legacy Insurance is a licensed health insurance agency and is not affiliated or endorsed by the government or Federal Medicare program. The submission data for this form is encrypted to HIPPA standards by GoHighLevel.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please visit Medicare.gov or call 1-800-MEDICARE to get information on all of your options.

Legacy Insurance represents Medicare Advantage (HMO, PPO, PFFS) organizations and standalone PDP Prescription Drug plans that have a Medicare contract. Enrollment depends on the plan’s contract renewal.

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We are not affiliated with Medicare, the U.S. government, or any state or federal agency. This is an advertisement. Callers will be connected with a licensed insurance agent who may offer Medicare Advantage plans (HMO, PPO, PFFS), Medicare Supplement, and stand-alone prescription drug plans (PDP). We do not offer every plan available in your area. Currently, we represent 6 organizations which offer 2352 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment is subject to the plan’s contract renewal.

What’s Your Name?

What’s Your Email?

What’s Your Address?

What’s Your Phone?

What’s Your Preferred Pharmacy?

What’s Your Preferred Hospital?

Who Are Your Physicians?

What Prescriptions Do You Take?

Scope Of Sales Appointment Confirmation Form