Medicare Renewal

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Business Name*

Insured Name*

Email*

Phone*

Mailing address*

Street Address Address Line 2 City State ZIP Code

Verify what Medicare plans, what coverage do you have now?*

What do you like about your current coverage?*

What would you add/alter to make your coverage better?*

Any particular ways you use your coverage that I should be aware of?*

Do have any preference on the network of plans:*

HMO

PPO

No Preference

Do you make your plan decision or does someone help you make your decisions?*

I make my own

Someone else

Who helps you with the descision*

Would you like me to check if any of your current doctors are in-network?*

Yes

No

Name of Doctor’s office and location*

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Would you like me to check if your Rx drugs are covered and at what cost?*

Yes

No

List*

Name of the drug

Dose size

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Current Pharmacy used?*

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The Salvati Insurance Group, Inc.
Monday - Friday: 8:30 A.M. -4:30 P.M.
42370 Van Dyke Ave, Suite #711
Sterling Heights, MI 48314
Phone: 248-720-1130

The Salvati Insurance Group is proud to be named one of the Best and Brightest Companies in the NATION to Work for in 2022, 2024 and the Metropolitan Detroit for 2021, 2022, 2023 and 2024. Our commitment to a culture of excellence is reflected in all we do and extends far beyond the walls of our office.