Schedule an Appointment - Howard Insurance Agency

Step 1 of 2

Choose a Time

Appointment Type

Duration

If you are new to Medicare or this is our first time talking, please be sure to schedule a 60 minute appointment.
If you would like to set up an in-person meeting or schedule an appointment outside office hours, we are available - please call 971-278-9022 to set that up.

Step 2 of 2

Your Information

First Name

Last Name

Gender

Female Male

Date of Birth

Phone

Zip Code

County (optional)

Notes (optional)

Please fill in all required fields.

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Scope of Appointment

The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

Please check beside the type of product(s) you want the agent to discuss.

Medicare Advantage (Part C) Medicare Supplement (Medigap) Medicare Prescription (Part D)

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you indicated above. Please note, 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 enrollment, or enroll you in a Medicare plan.

Signature (Beneficiary Full Name)

By checking this box, I indicate that I have read and understand the contents of the Scope of Appointment form, and that I confirm that the information I have provided is accurate.

Please confirm the Scope of Appointment to continue.