Thank you for allowing us to assist you with your Medicare needs. Medicare is not a "one-size fits all" product, that is why we represent all of the major carriers for Medicare Supplements, Medicare Advantage and Medicare Part D Drug Plans.In order to assist us in identifying the best Medicare options from which you will choose, please complete the following information. We will reply with your Medicare Recommendations Report. This information will remain confidential and will only be used to assist you in identifying and understanding your Medicare options. In the meantime, please feel free to call us at 1-(800) 945-1953 or e-mail us at

Medicare Planning Worksheet
Select all that apply
Do you currently have Medicare Parts A & B?*
Select all that apply
Do you intend to continue using this doctor in the future?*
Are you interested in plans that provide optional benefits such as dental (preventative and comprehensive), vision (exams and eyewear) and hearing (exams and hearing aids)?*
Do you occasionally travel outside the United States?*

Please Rank Level of Importance   *Denotes Required Field

Having no out-of-pocket costs
Low monthly premium
Low co-pays
Cost of medications
Flexibility in choosing my doctors
Extra benefits such as dental, vision and hearing, health club membership
Quality rating of plan
Focus on preventative and health
Do you receive extra assistance from the government for your health care costs?