Questions? Call me at (501) 658-5127
Drag and drop the fields to create your own form
Digital Signature for Scope of Appointment
Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.
By entering your information below and clicking Submit, you are giving permission to have a licensed sales agent contact you by email, telephone or cell phone to provide additional information about products and services. Your consent is voluntary and allows us to contact you via email, text messaging, artificial or prerecorded voice messages, or automatic dialing for marketing purposes. You may contact us to change your preferences at any time. Data use charges and rates from your cellular carrier may apply.
By signing this form, you agree to be contacted by a licensed sales agent to discuss the types of products you selected above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.
The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.
Tammy Chase, AssureSource
7600 Highway 107
Sherwood, AR 72120
Tammy Chase is a Licensed Insurance Agent. Arkansas License #17686965.
© Copyright 2021 Tammy Chase, AssureSource. All rights reserved.
Insurance Websites powered by AgentMethods.