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By submitting this form you agree that a licensed insurance agent employed with e-TeleQuote Insurance, Inc. may contact you regarding health and life insurance products and services including Medicare Advantage, Medicare Supplement and Prescription Drug plans or Life Insurance plans by phone or email. You expressly consent to receive phone calls (including autodialed and/or pre-recorded calls) and email using automated technology at the phone number and email address you provided, even if it is a wireless number, regardless of whether you are on any Federal or state DNC ("Do Not Call") and/or DNE ("Do Not Email") list or registry.

Online quotes may not be available for all Medicare Advantage, Medicare Supplement and Prescription Drug plans, but the licensed agent that will be discussing these plan options with you is contracted with various Medicare health or prescription drug plans that are not under the Federal government Medicare program, and the licensed agent may be compensated based on your enrollment in such a plan. Submitting this form does NOT affect your current Medicare Part A and Part B enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan.

Receiving quotes through our website and from our licensed agents is always free and you are under no obligation to purchase any goods or services as a result of this request. You may receive surveys of service, account updates or other special offers via email sent by e-TeleQuote Insurance, Inc. You may revoke your express consent at any time by contacting us via phone 1-877-336-1489 or email at so that you may be placed on our do-not-call and/or our do-not-email list.