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1. I acknowledge and understand that neither Heritage Wealth Management nor Advisors Excel, LLC or any of their respective representatives are affiliated with Medicare, CMS or any government agencies.
2. I give my written consent for representatives of Heritage Wealth Management, 11075 S. State St., Suite 9A, Sandy, UT 84070 and/or Advisors Excel, LLC, 2950 SW McClure Rd, Topeka KS 66614 to contact me about Medicare via any of the contact information I have provided in this form.
3. I hereby request a Medicare quote. I acknowledge and understand that I will be contacted by a licensed insurance sales agent regarding the purchase of a Medicare Supplement policy and/or a Medicare Advantage plan.
4. Coverage purchased after initial enrollment period are subject to eligibility requirements. Guarantees are backed by the financial strength and claims-paying ability of the issuing insurer.
5. 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.
6. By providing the information above, I grant permission for licensed insurance agent, Heritage Wealth Management, to call or email me regarding my Medicare options including Medicare Supplement, Medicare Advantage, and Prescription Drug Plans.