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

This Online Application is on a Secure Server. Click on the "lock" in the URL line 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.
11370 Grand River Rd.
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 that fits your needs. This information will be kept confidential and will be used for consultation purposes only.

Contact Authorization
By providing the information below, I grant permission for a licensed insurance agent to contact me regarding my Medicare options including Medicare Supplement, Medicare Advantage, Prescription Drug plans.

Personal Information
Name:
Address:
City:   State:   Zip:
Day Phone:   Night Phone:
Best Time To Call:   AM   PM
Email Address:
Month/Year 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.

   

  • 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 or 1-800-MEDICARE to get information on all of your options.

  • Not affiliated with or endorsed by the government or federal Medicare program.

  • Participating sales agencies represent Medicare Advantage [HMO, PPO, PFFS, and PDP] organizations that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
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.