State Specific Privacy Addendum Request

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State*

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Last Name*

Email*

Address*

Phone

Subsidiary or Affiliated Entity

AmeriLife Office Location

Primary Contact at AmeriLife

Policy or Account Number

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Not affiliated with the U.S. government or federal Medicare program.

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.

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