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This serves as an invitation to explore insurance options I am requesting information on (i.e., Life insurance, Medicare, Prescription Drug Plans, etc),
By submitting this form, I consent to being contacted by a licensed insurance agent for the promotion of insurance products I may be interested in.

I acknowledge that the individual contacting me for discussions on insurance products is licensed and certified.
It is understood that this person is not affiliated with or employed by the Federal government.

This form should be completed by the person seeking enrollment in a insurance plan or their authorized representative. Submitting this
form indicates my agreement to engage in a discussion with a licensed insurance agent to explore coverage with insurance products.

I know I am under no obligation to purchase anything. And I understand all consultations are offered without charge.

All information supplied on this form is confidential and will not be sold to third parties.

1438 Wildwood Court Grass Lake, MI
Important disclosures about Medicare Plans: Medicare has neither endorsed nor reviewed this information. Not connected or affiliated with any United States Government or State agency. 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 contact or 1-800-MEDICARE to get information on all of your options.

Senior Sure Care