Medicare information request form

Have questions about Medicare insurance coverage? Fill out your information below to be contacted by a Dean Medicare representative. If you are turning 65 and need current year plan information, call one of our Dean Medicare Representatives directly at 1-877-234-0126 (TTY: 711).

I want to receive an information packet and be contacted by a licensed Medicare representative.

First Name

Last Name

Phone

format: 000-000-0000

Address 1

Address 2

City

State

ZIP Code

In what county does the prospective applicant live?

I currently have a Medicare plan. No, I do not have a Medicare plan.

I consent to receive Medicare Advantage marketing communications via email and mail and to be contacted by a licensed Medicare Representative from Dean Health Plan. I am aware that I may opt out via unsubscribing from emails or calling Customer Care to be removed from the mailing list.

How did you hear about us?