By providing the information in this form, you are granting permission for a licensed insurance agent to contact you via phone regarding your Medicare options including Medicare Supplement, Medicare Advantage, and Prescription Drug Plans.

Charter Financial Group is a licensed health insurance agency and is not affiliated or endorsed by the government or Federal Medicare program. The submission data for this form is encrypted by Amazon Web Services.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

Charter Financial Group represents Medicare Advantage (HMO, PPO, PFFS) organizations and standalone PDP Prescription Drug plans that have a Medicare contract. Enrollment depends on the plan’s contract renewal.

What's Your Email and Phone for contact?

What's Your Address?

Plans vary depending on zip code and county.

By providing the information in this form, you are granting permission for a licensed insurance agent to contact you via phone regarding your Medicare options including Medicare Supplement, Medicare Advantage, and Prescription Drug Plans.

Charter Financial Group is a licensed health insurance agency and is not affiliated or endorsed by the government or Federal Medicare program. The submission data for this form is encrypted by Amazon Web Services.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

Charter Financial Group represents Medicare Advantage (HMO, PPO, PFFS) organizations and standalone PDP Prescription Drug plans that have a Medicare contract. Enrollment depends on the plan’s contract renewal.

How Familiar are you with Medicare?

What do you have for coverage now?

Please list your prescriptions you are taking or write NONE if you are not taking any.

Ensure to enter dosage too.

Who's your primary doctor?

Write NONE if you don't have one or don't have a preference.

Please list any specialists you have. Write NONE if you have none.

What's Your Date of Birth?

Great! You're All Set!