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Permission to Contact

Fill this out so Dean Vella of Proper Coverage Insurance can contact you about Medicare and related insurance options. You choose how you want to be reached and what you want to discuss — and you can opt out at any time.

Your contact information

First name *

Last name *

Phone *

Email *

ZIP code *

Time zone

How may Dean contact you? *

Check all that apply. Leave unchecked any method you do not authorize.

Phone call

Text message (message and data rates may apply; reply STOP to opt out)

What would you like to discuss? *

Check all that apply. The agent may only discuss what you select here.

Medicare Advantage

Medicare Part D (prescription drug coverage)

Medicare Supplement (Medigap)

Other

If "Other," please specify

Your consent *

By submitting this form, I, [your name], request that Dean Vella of Proper Coverage Insurance contact me about Medicare and related insurance options using the methods I selected above.

I understand that:

This consent is specific to Dean Vella / Proper Coverage Insurance.
This consent expires 12 months from the date below unless I renew it.
I may opt out at any time — reply "STOP" to a text, click "unsubscribe" in an email, or call 407.603.1913.
I am a resident of the United States and I am at least 18 years old.
This request for contact was initiated by me.

Proper Coverage Insurance is an independent insurance agency and is not affiliated with or endorsed by the Centers for Medicare & Medicaid Services (CMS), the Medicare program, or any other federal or state government agency.

I have read and agree to the consent statement above. *

Signature *

Typing your full name below serves as your electronic signature.

Signature (type your full name) *

Date *

There is no cost to you for Medicare guidance; agents are compensated by the insurance carriers. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options. See our Privacy Policy.

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