Questions...Call 888.995.2821
 Our Medicare Specialists are standing by... 		 

 

.: Home
 .: About Us
 .: Health Links
 .: Companies
 .: Contact

.: Link Partners

.: Privacy Policy

 

.: Individual & Family
 .: Group Health

.: Large Group Health

.: Dental Plans

.: Short Term
 .: Medicare Insurance
 .: Life Insurance
 .: Long Term Care
 .: Disability Insurance
 .: Student Health

.: Travel insurance

.: Annuities

.: Annuities - FAQ's

.: Glossary of Terms

.: COBRA - FAQ's

 
 

 

                                                                                                    

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

          

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please enter your Information below to schedule a Home Visit from one of our Trained Medicare Specialists, Request a FREE information Kit, or Schedule a Call.  All information you provide is Strictly Confidential, secure and used for the sole purpose of finding you the best Medicare plan.  Thank you for visiting and we look forward to serving you!

 

About You
* Your First Name
* Last Name
* Email Address
* Email address (retype)
* Street Address
* City
*
* County
* Zip Code
() - Ext. * Phone Number (Day)
() - * Phone Number (Evening)
() - Fax Number
 
Your Health Insurance Information
Do you currently have Health Insurance?
Yes No
If "Yes", when does your current policy expire?
If "Yes", who are you currently insured with?
Are you a Male Female *
/ / * What is your Date of Birth?

* Please select the Plan & Carrier you desire.  Aetna, AARP, Humana, etc.

Are you eligible for open enrollment? Turning 65? New to Medicare? Disabled? 
Yes No Don't Know
Have you been confined to a hospital within the last 2 years?
 Yes No
In the last 6 months have you been treated for a heart disorder or skin cancer?
 Yes No
Are you waiting or confined to the hospital, nursing home, or been discharged in the last 10 days?
 Yes No
Have you been advised to have surgery or procedure and not done so?
 Yes No
Are you currently covered under MEDICARE parts A or B?
 Yes No Don't Know
Optional coverage (check the ones you may want)
Life Insurance Long Term Care
Fixed Annuities Senior Auto
Details/Comments/Remarks
Any Comments / Questions?
Want to receive relevant information from eBenefitsByDesign.com?
 Yes No
**For the courtesy of our Insurance Partners, please submit this inquiry only if you are truly interested.

By giving eBenefitsByDesign.com your e-mail address or telephone number, you agree to allow eBenefitsByDesign.com to contact you with information related to its health benefits plans, products, services and/or educational information related to health care.
 

 

 

 

Copyright 2005-2009 eBenefitsByDesign.com All rights reserved. | 01/04/2010 09:38 AM

Our Privacy Policy  *  Terms of Use