Scope

SCOPE OF APPOINTMENT CONFIRMATION FORM

* Indicates required field

Clients *

1. *

Medicare Advantage Plans (Part C) and Cost Plans

2. *

Stand-alone Medicare Prescription Drug Plan (Part D)

Licensed sales representative first and last name: *

Dana Gaffney

I am not the beneficiary. I am his/her authorized representative (Power of attorney, etc..) *

Yes No

Beneficiary first and last name * *

First

Last

Beneficiary phone number *

This is an immediate appointment. Time and date will be stamped on the email that is populated from this form

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Beneficiary/Authorized representative signature *

First

Last