Annual Enrollment Period 10/15 - 12/7
858.568.4911

Better
Medicare
Starts Here.

Jill
"The MedicareLady"

Independent broker specializing in Medicare Insurance options throughout California.

JILL ANN LACKEY CA. INS. LIC. #0G53547.

!Covid-19: to ensure everyone’s safety, in person meetings will be replaced with this intake survey.

Please fill out the intake survey below.

I will use the information provided by you to run a 2021 comparison prior to contacting you for a phone appointment at which time we will discuss if there is a benefit to changing plans for the upcoming year or if it is best to stay on the coverage that you currently have.

Click Start Survey to begin...

1/5Intake Survey

2/5What plan(s) do you currently have now?

3/5Current Prescriptions

Please enter your current prescription(s), whether they are brand or generic, the quantity per day/month, and your current dosage.

4/5What is the name of your pharmacy of choice?

5/5Remarks