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Medicare Quote Form

Contact Info & Consent

Full Name

Email *

Phone *

State

Postal Code

By submitting this form, I agree that a licensed insurance agent from Fortune Shield Insurance Agency may contact me by phone, text, or email about Medicare Advantage, Prescription Drug, or Medicare Supplement plan options. I understand this is a solicitation for insurance. My consent is not a condition of purchase, and I may opt out at any time.

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Coverage Basics

Are you currently on Medicare?

Yes

No

If Yes Enter Part A/B Effective Dates

If No Will you be eligible soon?

Do you currently have:

MAPD (Medicare Advantage)

Med Supp (Medigap)

PDP (Prescription Drug Plan)

None

Doctors & Medications

Would you like help finding plans that fit your current doctors or medications?

Yes

No

Not sure yet

If yes, we will ask for those at a later time.

Plan Preferences

What’s most important to you? *

Keeping monthly costs low

Broad provider network (dentists / vision clinics)

Comprehensive benefits (higher annual maximums, lower copays)

Bundling with existing health or life coverage

Do you qualify for Extra Help/LIS or Medicaid?

Yes

No

Unsure

By submitting, I agree that a licensed agent from Fortune Shield Insurance Agency may contact me about Medicare plan options. Not affiliated with or endorsed by the U.S. government or Medicare. Consent not required to purchase. Information used only for quoting purposes. *

Yes, I agree

*A Scope of Appointment will be completed before discussing any specific Medicare plan details, benefits, or costs.

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Accessibility Statement

Fortune Shield is a licensed, education-first protection resource. NPN: 1073776. Not all products are available in all states. Eligibility and benefits vary by carrier and state. Enrollment subject to approval. Fortune Shield is not connected with or endorsed by the U.S. government or the federal Medicare program.

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