Enrollment request & Scope of Appointment

Fill this out once — we'll use it for both forms. Takes about 5 minutes.

My enrollment request

I want to enroll intoEffective date

with ARVF, INC dba EIG Senior Care as my Medicare Licensed Agents.

My information

Full nameHome addressPhoneEmail (optional)Medicare number (on your red, white & blue card)Date of birth

Primary care doctor

Scope of Appointment

Check the type(s) of product you want the agent to discuss:

Stand-alone Medicare Prescription Drug Plans (Part D)Medicare Advantage Plans (Part C) and Cost PlansDental/Vision/Hearing ProductsHospital Indemnity ProductsMedicare Supplement (Medigap) Products

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you checked above. The person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. Signing this form does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan.

Sign

Type your full name as your signature

Signing for someone else? (authorized representative)

Representative's nameRelationship to the beneficiary

I agree that typing my name above is my electronic signature on the enrollment request and Scope of Appointment.