Medicare Referral Form Step 1 of 3 - Agent Info 33% Referral Agent Name* Who is your GM Marketer?* Referral Agent Phone*Referral Agent Email* Referral Agent Mailing Address For Payment* Referral First Name* Referral Last Name* Referral Phone Number*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingHow Can We Help?*What Should We NOT Discuss? We will do our very best to find the right policy for your referral. Although we have contracts with most carriers, we are not contracted with every single company. Should another company be better suited for your referral, we will direct them to the carrier (which can happen on a PDP plan as not all PDP plans contract with agents). We will keep you updated on the status of your referral. When/If we are able to enroll the referral in a qualifying plan, your referral fee will be paid by check to the address provided. If you have any questions, please contact Elisha Brewer, Referral Program Manager via email: email@example.com. Thank you, we promise to take great care of your referral! *Guaranteed Issue Supplements are excluded *If we do not get paid by the carrier, we cannot pay a referral payment.