Complete the Preliminary Information Form

Please complete the Preliminary Information Form so I can prepare a Medicare insurance quote. Click the tab below to open the Preliminary Information form for you to fill out, save, and email the completed form back to me at

NOTE: It is important that you include your prescriptions and doctor’s names to help me quote plans that include your prescriptions and doctors.

If you want a quote for Advantage plans and another quote for Supplement (Medigap) plans, these will be separate quotes.

If you change your mind and want to avail yourselves of my full services as a Medicare agent, broker, and advisor, please email a request that you want to use my full services or fill out the START HERE below:

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