Initial Medicare Supplement Kit Request

We Need to get you appointed BEFORE you can write business. Please download the licensing, fill out and fax or email back with a current copy of your NYS insurance License.

Download Licensing here: http://files.lrcassoc.com/FUA/DataSheet.pdf

Complete the the form below and we will send your initial Medicare Supplement kit and a link to the power point presentation right out to you.

* Required fields
Name *
E-mail Address *
Are you appointed with First United American? *	Yes No
If so, with what agency?
Do you want the initial Medicare Supplement kit? *	Yes No
How would you like your presentation	Power Point Adobe .pdf
Address (for sending your kit) *
Primary Phone Number
Secondary Phone Number
Fax Number

I have read and agree to the Privacy Policy *

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Questions:

Email: todd@lrcassoc.com
Phone: 1-800-443-5149
Fax: 1-845-425-9312