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Home
Request an Appointment
Contact
About
What We Do
Who We Are
Who We Represent
What We Offer
Testimonials
Requesting an Appointment / Scope of Appointment
Please check which applies:
I am already scheduled for an appointment with Coveside
I am requesting an appointment with Coveside
Please check which applies:
I am new to Coveside
I am currently working with Coveside
Please check which applies:
I am becoming Medicare Eligible
I am already Medicare Eligible
My current health plan is:
An Employer plan
An Individual plan
A Medicare plan
Name
*
First Name
Last Name
Message to Coveside
Email
*
Address
Phone
(###)
###
####
Kindly complete the required Scope of Appointment form below:
I understand that I am requesting a meeting with an independent insurance agent at Coveside Healthcare Coverage Options who has a contract with Aetna, Anthem, Humana, Martin’s Point Generations Advantage, and UnitedHealthcare, and to offer their Medicare plans.
Yes
No
I understand that the representative will be discussing Standalone Medicare Prescription Drug Plans, Medicare Advantage plans, and other Medicare-related products, such as Medicare Supplement plans or Dental, Hearing, Vision.
Yes
No
I understand that the person who will be discussing these plans are contracted by private companies who have a Medicare contract to offer Medicare Advantage, Medicare Prescription Drug, and Medicare Supplement plans.
Yes
No
I understand that if I agree to this appointment, there is no obligation to enroll, current or future Medicare enrollment status will not be impacted, nor will it automatically enroll me in a Medicare Advantage Plan, Stand-alone Prescription Drug Plan, or other Medicare-related product.
Yes
No
I understand I am not required to provide any health-related information to our insurance agents unless it will be used to determine enrollment eligibility.
Yes
No
By Typing My Name Below I am Acknowledging Acceptance of the Above
*
Today's Date
*
MM
DD
YYYY
Thank you!