Medicare Questionnaire

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Explore Your Medicare Coverage Options

We would like to provide you with more information on Medicare. Please provide as much information as possible, and we will contact you within one to two business days to discuss the Medicare plan that fits your needs. This information will be kept confidential and will be used for consultation purposes only.

Contact authorization

By providing the information below, I grant permission for a licensed insurance agent to contact me regarding my Medicare options, including Medicare Supplement, Medicare Advantage, and Prescription Drug plans.

Personal information

Name

Address

City

State

Zip code

Phone number

Email address

Month/year of birth

Coverage information

Check any of the following sources if you currently receive health or drug coverage:

Coverage from the VA (Veterans's Administration)

Coverage from your Union

Coverage from your Current Employer

Coverage from your Former Employer

Coverage from Other Source

Do you currently have Medicare Part A?

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Do you currently have Medicare Part B?

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Additional comments

Please share any additional comments or questions you have about Medicare.

• We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact medicare.gov or 1-800-MEDICARE to get information on all of your options.

• Not affiliated with or endorsed by the government or federal Medicare program.

• Participating sales agencies represent Medicare Advantage [HMO, PPO, PFFS, and PDP] organizations that are contracted with Medicare. Enrollment depends on the plan's contract renewal.

Submit an inquiry

If you would like more information about Tom Storm Insurance Agency, please stop by our office, call us, or fill out the form below.

Privacy Statement: Any information provided by a consumer or customer through our online forms will be held in the strictest confidence. We will not share information with others. All submissions will receive a response within two business days.

Tom Storm Insurance Agency, Inc.
11370 Grand River Rd.
Brighton, MI 48116

Phone: 810-588-6310

Fax: 800-550-1785

Email: karen@tomstorminsurance.com