Medicare

Please fill out this form to advise us as to which Medicare plans you would like an agent to discuss with you.

Fill Out Online
  • All information is entered, submitted, transferred and stored securely.

Download the PDF

Under 65

This letter presents your engagement with Susan Polk Insurance, including a disclaimer and waiver regarding electronic data transfers.

Fill Out Online
  • All information is entered, submitted, transferred and stored securely.

Download the PDF