Basic Medicare Insurance provides excellent coverage, but because of no stop-loss reimbursement, you end up paying a lot for your medical care. We recommend purchasing a Medicare Supplemental plan. Fill out the preliminary form below and an agent will contact you. We will not distribute your name, e-mail, phone or address to others.

General Information Name: Address: City:   State:   Zip: Phone: Email Address: Date of Birth (mm/dd/yy):        Age:       Sex: M F What is the best way to contact you?: Phone   Email What time of day is best to contact you?:   a.m.   p.m. Are you eligible for Parts A & B of Medicare?: Y N Additional Comments Please list any questions or comments you may have about Medicare Supplement Insurance

Pacific Benefit Consultants, Inc. 450 Country Club Rd. Suite 330 Eugene, Oregon 97401 (541) 484-6624 (541) 686-2726 (Fax) (800) 588-8688 (Toll Free)

 

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