Information Mailing Request


Please complete below and we will mail you a kit that includes: consumer booklets;  Medigap Plan F age-based  quotes/material from insurers; and  Part D Prescription plan information.  As an optional service to you, if you feel comfortable telling us your current prescriptions, we will include a written  analysis of your specific expected prescription co-pays and whether or not we feel the "doughnut hole" may apply in 2011. Or simply call us at 215-794-7418 anytime!

First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Date of Birth
Required
/ /
Gender
Required
Do you have a Medicare Parts A+B card or a letter from Medicare?
Required
Current Insurance Provider
Required
Is your spouse also interested in coverage now?
Optional
Prescriptions taken daily/regularly (this information is optional, but if you wish, we can provide a written analysis of your specific expected prescription co-pays)
Optional
Submission Validation
Required
CAPTCHA
Change the CAPTCHA codeSpeak the CAPTCHA code
 
Enter the Validation Code from above.
Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.


Penn Health Insurance Solutions, Inc.
2960 Ash Mill Road / P.O. Box 309
Holicong, PA 18928
ph: 215-794-7418 / fax: 215-794-7436