1️⃣
3 Mins Video
2️⃣
Interest Form
3️⃣
Get a Personalized Plan
4️⃣
Enroll in Medicare
5️⃣
Final Review
BBR Multi-Step Form
Personal Info
Coverage & Premium
Final Details
Step 1: Personal Information
First Name
Last Name
Email
Phone
Age
Zip Code
Marital Status
-- Select --
Single
Married
Medicare # (If Any)
Next
Step 2: Current Coverage
Do you currently have a/an … ?
Term Life Policy
Cancer Policy
Dental Policy
Vision Policy
Accident Policy
Gym Membership
Medicare Supplement
Drug Card
Total Monthly Premium Range
If you have any policies
listed
, choose your
combined monthly premium
.
Less than $100 /mo
$100 to $300 /mo
$300 to $500 /mo
More than $500 /mo
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Next
Step 3: Final Details
Most Important Doctor(s)
Most Important Drug
Home Owner
I agree to be contacted by this company
Scope of Appointment (SOA) Exception: I request and authorize BBR to call me before the 48-hour waiting period
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Submit & Continue
Even if you started a plan with another agent - it's not too late to do BBR!
