Part D Questionnaire

Medicare Part D Questionnaire
(Annual enrollment Period 10/15 - 12/7)

* Indicates required field

Name *

First

Last

DOB *

Spouse's Name *

First

Last

Spouse's DOB *

Phone Number *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

What is the name of your preferred pharmacy, include any other pharmacies you will consider *

My current PRESCRIPTION DRUG PLAN is *

My current monthly premium for my DRUG PLAN *

Spouse's DRUG plan (if applicable) *

Spouse's monthly PRESCRIPTION DRUG PLAN premium *

Please list all Medication, Dosage (tab or cap) and the Quantity per day: *

Please list 2-3 preferred pharmacies you WILL go to *

Questions?
Call Maureen at 608-234-1521.
Thank you for choosing Binning Insurance!

Submit

Maureen Binning
Senior Services Specialist
[email protected]
(608) 234-1521

Have Questions? Ready to Get Started? Contact us for a free consultation. Work with Binning Insurance to help find the Medicare coverage right for you.

We do not offer every plan available in your area. Currently we represent 22 organizations which offer 85 products in your area. Please contact Medicare.gov, 1–800–MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Medicare Part D Questionnaire(Annual enrollment Period 10/15 - 12/7)

Contact Maureen

Medicare Part D Questionnaire
(Annual enrollment Period 10/15 - 12/7)