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Let's Build Your Plan!

Select Your Open Enrollment Period

YOUR AUTHORIZATION IS REQUIRED BY LAW

Before we are allowed to assist you with your Medicare needs, we will first need your written authorization to do so. Please review and complete this agreement at this two days prior to your appointment with yiour agent.

Scope of Sales Appointment Confirmation Form. The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any individual sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative at least two days prior to the meeting with your agent..

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above. Please note, the person who will discuss these products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. Signing this form does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan at this time.

PLEASE STOP HERE AND CLICK "NEXT" TO MOVE ON TO THE NEXT QUESTION. THE BOTTOM HALF OF THIS PAGE NEEDS TO BE COMPLETED BY THE AGENT.

Medicare Member Profile

Member Health History

Member Income Information

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LET'S BUILD YOUR CUSTOM PLAN

Medicare and other health benefits are highly customizable. This means that we can select higher or lower levels of coverage based on your specific health needs and your financial situation.

In this last section, we will ask series of multiple choice and yes or no health questions that will help us narrow down from the thousands of options that are available to only those options that match your specific needs.

I will be asking for your financial snapshot as well. There are numerous programs available to almost every income level and we help determine which programs (if any) that you qualify for. Your answers don't have to be exact so if you're unsure, just give us your best guess.

WHICH TYPE OF PLAN HAVE YOU BEEN COVERED UNDER IN THE LAST 60 DAYS?

WHICH PLAN ARE YOU MOST INTERESTED IN?

FAMILY HISTORY ACUTE CARE

FAMILY HISTORY - CHRONIC CARE

ORAL HEALTH

OPTICAL HEALTH

HEARING HEALTH

LET'S ASSESS YOUR RISK OF CATASTROPHE

FINANCIAL SNAPSHOT

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IMPORTANT MESSAGE!

Once you click the submit button, you'll be taken directly to my calendar where you can book your 30 minute plan recommendation appointment. If you've already booked this appointment with your agent, then after you submit your form, you can simply close out the window. This meeting will take approximately 30 minutes over the phone and computer (best for viewing). We will spend this time going over your proposal and recommendations as well as all of your questions.

It will take approximately 24-48 business hours to complete your assessment. In the meantime, if you think of anything that might be important for us to know, or if you have any questions, please reach out via text, email or phone.

OFFICE: 866-758-7229 - CALL OR TEXT: 520-272-5950]
EMAIL: tracy@snibrokers.com - ON THE WEB: www.snibrokers.com

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