Name: Guardian Angel Insurance
Price range: $$

Comments

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Requested Effective Date for Coverage

I consent to contact*

Yes

Client Information

Name*

First Last

Email*

Phone*

SMS Consent

By checking this box, you consent to receive text messages from Guardian Angel Insurance at the mobile number provided regarding your insurance inquiries, quotes, and policy updates and promotional/marketing messages. Consent is not a condition of purchase. Message and data rates may apply. Message frequency varies. Reply HELP for help or STOP to cancel. View our Privacy Policy and Terms of Service

Date of Birth*

Gender*

Male

Female

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Spouse Name

For household discount purposes

Spouse Date of Birth

Current Medicare Plan (if available)

Please skip to the next section if you do not currently have a medicare plan.

Medicare ID (if available)

Retirement Effective Date

Medicare Part A Effective Date

Medicare Part B Effective Date

Current plan coverage and monthly premium

Are you a smoker?

Yes

No

Physicians

Primary Care

First Last

Address

Specialist

Type of Specialist

Name

First Last

Address

Add Specialist 2

Add another specialist

Specialist 2

Type of Specialist

Name

First Last

Address

Add Specialist 3

Add another specialist

Specialist 3

Type of Specialist

Name

First Last

Address

Add Specialist 4

Add another specialist

Specialist 4

Type of Specialist

Name

First Last

Address

Hospital & Pharmacy

Hospital Preference

Preferred Pharmacy

Current Prescriptions

DO NOT list over the counter (OTC) vitamins, supplements, and/or prescriptions not purchased.

DO NOT state "as needed". Instead, provide an estimate based on the frequency you use the drug.

For inhalers, eye drops, creams, lotions, or ointments, provide size of bottle/tube and frequency of refills.

For insulin or injectables, provide units per day or pens per month.

List of Medications

Drug Name	Dosage	Package	Generic	Actions

There are no Medications.

Additional Information

Additional Comments

By responding to this request, I understand that I am not required to provide any private, protected health information (PHI). This information is only for use by Guardian Angel Insurance to help make an informed plan decision and will not be shared with any third party. I agree that an Guardian Angel Insurance representative may contact me by telephone, e-mail or US mail to discuss Medicare Advantage Plans, Prescription Drug Plans and Medicare Supplement Insurance Plans.

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