Scope of Appointment Form | Senior Benefits Unlimited

This form is required by Medicare before discussing specific plan options. Completing this form does not obligate you to enroll in any plan.

Client Information

Full Name Phone Number Email Address Street Address City State ZIP Code

Products to Be Discussed

Please check all that apply:

Stand-alone Medicare Prescription Drug Plans (Part D) Medicare Advantage Plans (Part C) and Cost Plans Dental/Vision/Hearing Products Hospital Indemnity Products Medicare Supplement (Medigap) Products

Appointment Details

Preferred Appointment Date Preferred Appointment Time Meeting Type

Consent and Signature

Electronic Signature (Type Your Full Name) Date Signed

I agree to be contacted by a licensed insurance agent to discuss the products listed above.

This form is not a contract and does not obligate you to enroll in any Medicare plan. By submitting this form, you acknowledge that you have authorized a licensed agent to contact you regarding the selected products.

This form is required by CMS for Medicare Advantage and Part D plan discussions.