General Information
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Zip Code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Part D Plan
Contact Information
Email
*
example@example.com
How would you like your comparison sent?
By Email only
By Mail only
Mail or email (no preference)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Prescription Information
Preferred Pharmacy
Our team will run the most efficient pharmacy if this field is left blank. Let us know here if you want us to look at one pharmacy exclusively
Do you take any medications?
*
Yes
No
How many medications do you take?
1
2
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Authorization and Statement of Understanding
*
I authorize Stevens & Associates Insurance Agency, Inc. (SNA) to run a comparative analysis of all available prescription drug plans available in my area and send recommendations to me along with a prepared enrollment form if recommended to change my plan.
*
I understand that although SNA does not have the ability to enroll members in all prescription drug plans nationally, they do review all plans available to me and will provide me the phone number to call-to-enroll if the recommendation is not a plan they can enroll me in.
*
I understand that I can call 1-800-MEDICARE if I would like to speak to Medicare directly about my options.
I acknowledge that I am a current Medicare Supplement client of SNA and understand this is a service exclusively provided to SNA Medicare Supplement clients. If I am not a current Medicare Supplement client, I will not receive a response to this request.
Signature
*
Clear
Date Signed
-
Month
-
Day
Year
Submit
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