SOA Testing - Senior Insurance Agency

Choose Your Agent*

Please initial below beside the type of product(s) you want the agent to discuss:

Stand-alone Medicare Prescription Drug Plans (Part D)*

Medicare Advantage Plans (Part C)*

Your Name*

Signature*

Date

Representative’s Name

Your Relationship to the Beneficiary

Agent Name

Agent Phone

Your Name

Beneficiary Phone

Beneficiary Address

Medicare ID Number

Initial Method/Location of Contact

Indicate here if beneficiary was a walk-in

Indicate here if beneficiary was a walk-in.

Agent’s Signature

File

Max. file size: 50 MB.

Plan(s) the agent represented during this meeting

PDP

MAPD

Date Appointment Completed

Plan Use Only