Medicare Waiver
I have reviewed the optional coverages below with my insurance agent. I will be declining the following lines of coverage(s) initialed below.





I understand that prescription drugs are not covered by Medicare Supplement Plans, and I may incur a penalty if I do not have qualifying prescription drug coverage in place.





I understand that Long Term Care Insurance is not included in Medicare, and without this coverage, I will not receive a benefit to pay for care that includes, but is not limited to, home health care, assisted living and/or nursing home care.





I understand that Life Insurance is not included in Medicare, and by declining Life Insurance, my estate and/or heirs may not be protected from potential financial burden.


 By way of signing this document, I hereby acknowledge that I have made the decision to waive my right to apply for the above initialed coverages at this time.

 I also acknowledge that this is against the advice of my agent and that by signing this document I am releasing any liability of my agent and Get Benefits Insurance Services, Inc. by any and all parties who have or may have right to bring claim against any party with regard to my decision to voluntarily waive the option to apply for the above coverages.

 I understand that if I desire to apply for the above coverages at a later date, that the price, availability of options for coverage may change for a variety of reasons, including, but not limited to age, penalty, health and market conditions.