Medicare Supplement & Medicare Advantage Plan Information

We would like to hear from you. Please provide us with some basic information and what you are interested in and we will furnish you with your information, or you may call us at (541) 434-9613 or (800) 884-2343.

Please note that the items marked with ** are required to submit the form.

If you are requesting information for Medicare Advantage plans, we only need to know your age & zip code.
If you are requesting information on Medicare Supplement plans, we will also need to know if you smoke or have any health conditions.

This is a solicitation for insurance. By providing this information, you agree that an authorized representative or licensed insurance agent/producer may coantact you by phone, email, or mail to answer questions or provide additional information about Medicare Advantage, Part D or Medicare Supplement Insurance plans.

Oregon Medicare Quote Request Form
Product Information
I am interested in information about the following products:
Medicare Supplement			Medicare Advantage

Personal Information - Please list all that you want quoted
First Name	Last Name**	Birthdate**	Gender	Height (in)	Weight (lb)	Smoke

Spouse (if you want quoted)


Contact Details
Address:
City:
State:
Zip Code:**
Contact Phone:
Email:**
Please Call:

Additional Information
Please list any relevant health information.
Solve the equation, then submit the form
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Oregon Health Insurance Plans

LifeWise Health Plans of Oregon

Regence BC BS of OR

Moda Health

PacificSource

Providence Health Plans

HealthNet of Oregon

Kaiser Permanente

Oregon Medical Insurance Pool

Medicare Supplement Plans

Medicare Advantage Plans

Other Insurance

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Medicare Supplement & Medicare Advantage Plan Information