Florida Free Medicare Analysis!

Vista Healthplan, Inc.

Thanks for using our services!

© 2004 J.A. MESSINA INSURANCE
PO Box 244571
Boynton Beach, FL 33424-4571
Phone: 561-736-2162
Fax: 561-736-0228
License#A177282
E-Mail us at:
jamessinains@comcast.net

For Your Convenience,
We gladly accept:

"All Our Policies Come With
an Agent!"

Need Coverage TODAY? After Submitting
Your Quote Form (see below), Call Toll-Free:
1-800-735-2162
Phone quote hours are Monday-Friday (9:00am-5:00pm Florida local time). To learn more about which MEDICARE+Choice Advantage Health Plan may be best suited to your situation, please complete the form below to receive your FREE ANALYSIS. We will respond with our finding within 24 hours!

FREE Medicare Analysis
One Simple Form - takes only 2-3 Minutes!

Your Personal Data

Your Name:

Street Address:

City:

Your "County" is?

State: MUST be Florida!

Zip Code:

E-Mail (REQUIRED):

E-Mail again for accuracy:

Phone:

Fax (optional):

Marital Status:
Single Married
Are You Retired?
Yes No

Health Ins. Currently?
(If yes, list carrier, and # of years
continuous. If none, type N/C)

Which age range do you fall into? 65-69 70-74
75-79 80-84
85 and up

Compared to others in your age group, which best describes your general health? Excellent
Very Good
Good Fair
Poor

Which of the following are you presently? Uniformed Service Retiree
Veteran (Veteran benefits)
Receiving health insurance through your current/former employer or union (or your spouse's emloyer/union)
Receiving Medicaid Benefits
None of the above

Do You Have end-
stage Renal Disease?
NO YES
Do You have permanent kidney failure?
NO YES

Have you had a successful kidney transplant?
NO YES
Do You have both Medicare
Parts A & B?
NO YES

Send my quotation via: E-Mail Fax
Regular Mail
Call me by Phone!

Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me My
Medicare Analysis NOW!

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