Proposal Request for Medicare

Please contact your Kistler Tiffany Benefits consultant with any questions. Please fill out the following information entirely.
Broker's Name
Broker's Address
Broker's Phone
Broker's Email
KTB Associate Broker works with:
Client/Prospects Name
Street Address
City
Zip
State
Phone
Email ( if available)
County of Residence, if known
Date of Birth: (not Age, but Date of Birth)
Medicare Part A	Yes No Effective Date of Medicare Part A
Medicare Part B	Yes No Effective Date of Medicare Part B
Current Status	Actively working Retired
Losing Current Coverage: Yes No
If Yes, please list reason:

Current Coverage: If you selected "other" please name your policy.
Current Drug coverage under Medicare Part D:	Yes No
List of drugs with exact name, dosage and frequency

Brief description of request or question from client