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Service:
New MEDICARE Client Office COLUMBUS
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Location:
Main Office
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Your Agent:
Kelly Parton
Date/time:
Sat, Mar 30 at 3:00 PM
(
EDT
)
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Please fill out the form below to schedule this appointment.
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First name
*
Last name
*
Email
*
Phone
*
Do you expect any life changes in 2020?
(e.g., marriage/divorce, newborns, retirement)
Street address
City, state, zip
How many tax dependents will your household have in 2020?
1
2
3
4
5
6
7
8
9
10+
Is this (number of tax dependents) change from 2019?
Yes
No
Not sure
Is your projected 2020 household income a change from 2018?
Yes
No
Not sure
What do you want to change the most about your plan from last year if anything?
(e.g., co-pays, deductibles, prescription coverage, physician network)
How did you hear about us?
Any other information you would like to share?
What do you project your household income to be in 2020?
Is this address a change from 2023?
Yes
No
Not sure
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