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PART D 2011
Client Survey
Customer Service
Click Here For:
 Your Medicare Part D Prescription Drug Comparison
Please fill out the attached form and and we will provide you with a prescription drug comparison for 2011. We will run your medications based upon the information provided. Please keep in mind that our Agency does not represent all the carriers. We will help you select a Prescription drug plan that will provide you with the most savings for your medication needs.

First Name:
 *
Last Name:
 *
Phone Number:
 *
Email:
Address:
 *
City:
 *
Zip Code:
 *
State:
YOUR MEDICATIONS FOR 2011
(Please provide your Medication Name Strength & Frequency)
Your Current Prescription Drug Plan:
Are you willing to take Generics?
Yes
No
Return Response by
Do not enter anything in this field:

* indicates a required field
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Insuring Futures Since 1984

           

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