To get more info and to help us recommend the best option, please complete the survey below to the best of your ability and submit. All of this information is optional and will not affect qualification; it simply helps us to recommend a plan that would be best suited for you.  Separate forms for husband/wife. 

It's helpful if we have this form in hand a few days prior to meeting.   It's also helpful if you can watch the Medicare video (link on Medicare/Senior Page).



Medicare Part B Premiums:

This next questions are not required but further helps us in our recommendations for you. Medicare Part B premiums are based on income from two years prior. That is, your 2020 income dictates your 2022 premiums.