Medicare Annual Enrollment & Review Questionnaire If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required First Name * Last Name * Date of Birth * Email Phone Please answer some questions about your current insurance. This will help our agents know what is important to you and they will look for plans that meet those needs. • You will receive a summary of benefits from your insurance company for the 2018 changes. Would you like us to review your insurance changes this year? * Yes No Are you happy with your plan(s) this year? * Yes No I am currently NOT taking any prescriptions Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Drug Name Drug Dosage Amount taken Each Day Comments Confirm that you are not a bot *
