This is a solicitation for insurance. By pressing 'Send' on this form, You are agreeing by your electronic signature to the Terms and Conditions and Privacy Policy that Insuranceratehelper and /or it's Partners , and/or a licensed insurance agent may contact you with marketing [promotional] offers with regards to health and life insurance products and services including Medicare Supplement, Medicare Advantage and Prescription Drug Plans and other health-related services by phone or email. You provide your express written consent via this chat / webform to receive phone calls (including autodialed and /or pre-recorded/artificial voice calls) and email using automated dialing system telephone call, text, or email at the phone number and email address you provided, even if it is a wireless number, regardless of whether you are on any Federal or state DNC ("Do Not Call") and /or DNE ("Do Not Email") list or registry. In addition, you understand and acknowledge that you are over 18 years of age and your consent is not required as a condition of purchase. Your consent can be revoked through any reasonable means by email/phone. I understand this request has been initiated by me and that this is an unscheduled contact request. I further understand that this request, initiated by me, is my affirmative consent to be contacted which is in compliance with all federal and state telemarketing and Do-Not-Call laws. And there is no obligation to enroll. Wireless carrier may impose additional charges on subscriber for messages (required for SMS). (Please note the Licensed sales agents are not connected with or endorsed by the U.S. government or the federal Medicare program)

My agreement does not affect my current or future Medicare enrollment status. This is effective as of [] and grants permission to discuss the above plan types.