Medicare Companion Information Request

Please note: This insurance plan is only available to Wisconsin residents.

To assure all your needs have been met, it is our practice to follow up by telephone with those who have requested information from us. By submitting this form you will be granting us permission to contact you via telephone in the future. Thank you for allowing us the opportunity to respond to your health insurance needs.

To receive a Medicare Companion quote, please fill out the following form or call us at: 1-800-236-1448.

Information About You  
Name:

E-mail Address:

Date of Birth:

Month
 

Day
 

Year

Phone Number:

( )  -

Address:


City:
 

State:
 

Zip:

County:

What type of insurance plan do you need?

Short Term Medical
Long Term Medical
Medicare Supplement

Type of Coverage:

Single
Family

Tobacco user?

 Yes
 No

Information About Dependents Seeking Coverage

Spouse's Name:

Spouse's Date of Birth:

Month
 

Day
 

Year

Number of Dependent Children:

Other

How would you like to receive your quote?

 E-mail
 Regular mail
 Telephone
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