Learn More about our Medicare Solutions

Please complete the form below to receive your free information package for any plan that interests you. There is no obligation.

*First Name: 
*Last Name: 
*Street Address: 
*City: 
*State: 
*Zip Code: 
Have a HAP Medicare Sales Representative call me: 
You can contact me by e-mail: 

Birthday:  

MM/YYYY

Please send me information about the plan(s) I have checked below:
Alliance Medicare Supplement
Alliance Medicare Rx (pdp)
HAP Senior Plus PPO
HAP Senior Plus (hmo-pos)-Expanded Network
HAP Senior Plus (hmo)-Henry Ford
 
My current health coverage is:
Original Medicare
Medicare Advantage HMO
Medicare Advantage PPO
Medicare Supplemental Plan (Medigap)
Medicare Prescription Drug Plan
Through my employer
I do not currently have Medicare. 
Not sure

Other Information :

Ford salary retiree
Ford hourly retiree
GM retiree
Other:

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