Tom Storm Insurance Agency, Inc. Tom Storm Insurance Agency, Inc. Independent Insurance Agent(R): The Trusted Choice(R) Karen Storm Tom Storm Insurance Agency, Inc.
Tom Storm Insurance Agency, Inc.

Free Insurance Quotes for Auto, Home, Life, and Commercial Insurance

Tom Storm Insurance Agency, Inc. Tom Storm Insurance Agency, Inc.
Tom Storm Insurance Agency, Inc.
Tom Storm Insurance Agency, Inc.

Secure Online Form...

Tom Storm Insurance Agency, Inc.
Assureguard EVSSL

This Online Questionnaire is on a Secure Server. Click on the seal above for more information on the certificate's authentication.

Privacy Statement: Any information provided by a consumer or customer via our online forms WILL be held in the strictest confidence. No information will be shared with others. All submissions will be responded to within two business days.


Blue Cross, Blue Shield, Blue Care Network
HAP
HUMANA


Tom Storm Insurance Agency, Inc.
10327 Grand River Rd. Suite 402
Brighton, MI 48116
  Google Maps
 
Phone:  810-588-6310
Fax:  800-550-1785
Email:  karen@tomstorminsurance.com

Email Tom Storm Insurance Agency, Inc.
Send Email
Tom Storm Insurance Agency, Inc. Tom Storm Insurance Agency, Inc. Tom Storm Insurance Agency, Inc. Tom Storm Insurance Agency, Inc.

Medicare Questionnaire

Tom Storm Insurance Agency, Inc.
We would like to provide you with more information on Medicare. Please provide as much information possible and we will contact you within one to two business days to discuss the Medicare plan right for you. This information will be kept confidential and will be used for consultation purposes only.

Personal Information
Name:
Address:
City:   State:   Zip:
Day Phone:   Night Phone:
Best Time To Call:   AM   PM
Email Address:
Date of Birth:

Coverage Information
Check any of the following sources if you currently receive health or drug coverage:
Coverage from the VA (Veterans's Administration)
Coverage from your Union
Coverage from your Current Employer
Coverage from your Former Employer
Coverage from Other Source
Do you currently have Medicare Part A?   Yes   No  
Do you currently have Medicare Part B?   Yes   No  

Questions or Comments
Please give any questions or comments you have about Medicare below:

Please click on the "Submit Request" button to send your questionnaire.
One of our representatives will respond to your submission as soon as possible.

   


Tom Storm Insurance Agency, Inc.
Tom Storm Insurance Agency, Inc.
Tom Storm Insurance Agency, Inc.
Tom Storm Insurance Agency, Inc.
Copyright (c) Tom Storm Insurance Agency, Inc.               Website Design by Enhanced Web Services
 
Important Note: This website provides only a simplified description of coverages and is not a statement of contract. Coverage may not apply in all states.
For complete details of coverages, conditions, limits and losses not covered, be sure to read the policy, including all endorsements.