Scope Of Appointment – Hall Biddle & Associates, Inc.

Scope Of Appointment Confirmation Form

Please check the products below, you want the agent to discuss.(Required)

Stand-Alone Medicare Prescription Drug Plan (Part D)

Medicare Advantage Plans (Part C) and Cost Plans

Dental/Vision/Hearing Products

Hospital Indemnity Products

Medicare Supplement (Medigap) Products

If you are the authorized representative, and not the Medicare Beneficiary, please check the box below

Authorized Representative

Beneficiary or Authorized Representative Signature Date(Required)

Beneficiary or Authorized Representative Signature(Required)

If you are the authorized representative, please sign above and enter your name below:(Required)

First Last

Your Relationship to the Beneficiary(Required)

Beneficiary Name(Required)

First Last

Beneficiary Address(Required)

Street Address City State ZIP Code

Initial Method of Contact(Required)

Walk-in

Inbound Call

Outbound Call

Book of Business

Referral

Other

Agent Name(Required)

Agent Phone Number(Required)

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Agent Signature Date