If you would like information or assistance that can help you decide which Medicare product(s) best suit your needs, fill in the questionnaire below, submit it, and we will give you a hand.

There is no charge, fee, or increase in premiums to use our services.

We will provide you with honest, accurate, friendly assistance at a time and place most convenient to you. We are Medicare Certified for 2010.

Robert J. Fortier CFP, CIC
Certified Financial Planner
Certified Insurance Consultant

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Contact Information: (We Service Connecticut Residents Only)

Name
Address Street
Town/City Zip Code
Date of Birth (mm/dd/yyyy)
Gender Male Female
Email Address
Phone Number Extension

Please send me information on Medicare Advantage plans
in my area which my doctors participate in
.

Doctor #1   Name Type of doctor Office zip code
Doctor #2   Name Type of doctor Office zip code
Doctor #3   Name Type of doctor Office zip code
Doctor #4   Name Type of doctor Office zip code
Doctor #5   Name Type of doctor Office zip code
Doctor #6   Name Type of doctor Office zip code

I would also like to considering my particular current prescriptions when helping me choose a plan.
This is optional, of course. But we advise considering your prescription use when comparing plans. Some plans may provide
better coverage for your prescriptions than other.

List All Prescriptions Below:

Prescription #1 times daily Prescription #2   Name times daily
Prescription #3   Name times daily

Prescription #4   Name times daily
Prescription #5   Name times daily
Prescription #6   Name times daily
Prescription #7   Name times daily
Prescription #8   Name times daily
Prescription #9   Name times daily
Prescription #10 Name times dail
y

Pharmacy(s) of choice:

Zip code
Zip code
Zip code


Please contact me, I have questions.

Call me to schedule an appointment.


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Buy submitting this form, your are giving Medicare Options, LLC permission to make contact with you for the express purpose of discussing Medicare Advantage plans, Medicare Supplemental Insurance (MediGap) plans, Part D Drug plans, or Medicare Parts A&B, as decided by you in the event of conversation. This is to protect you from receiving information on products or services you did not authorize. It also lets you know we respect your wishes.