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856-866-2020 or email info@lubenowagency.com.
Broker's Name


Broker's Address


Broker's Phone


Broker's Email


KTB Associate Broker works with


Client / Prospects Name


Street Address


City


State


Zip Code


Phone


Email, if Available


County of Residence, if known


Date of Birth (not Age, but DOB)


Effective Date of Medicare Part A


Effective Date of Medicare Part B


Current Status
Actively Working
Retired
Losing Current Coverage
Yes
No

If Yes, please list reason
 
--CURRENT COVERAGE--

Group (Non Medicare)


Group (Medicare carve out product like Personal Choice 65 or group Security 65)


Individual coverage-Non Medicare


Medicare coverage – Original Medicare without a supplement


Original Medicare with a supplement


Medicare Advantage plan like PC65, KC65 or Aetna Golden


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 or broker


 

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