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By submitting this form, I provide my express written consent for MAPDForSeniors, through its representatives, to contact me at the telephone number I provided, including via direct or electronic mail, (including any wireless number), text/SMS messages, live automatic/automated dialing systems, telephone calls, or email. This authorization overrides any previous registration on a federal, state, or corporate Do Not Call Registry or any internal privacy or solicitation preferences I have previously expressed. I understand that this is a solicitation for insurance products and services, including Medicare Supplement, Medicare Advantage, Prescription Drug insurance plans, and other health-related services. This request has been initiated by me and is an unscheduled contact request. It constitutes my affirmative consent to receive communications specifically from MAPDForSeniors. My consent is limited exclusively to MAPDForSeniors does not authorize any other entity or organization to contact me. I understand that consent to be contacted is not a condition of purchase, and I may revoke my consent at any time by contacting MAPDForSeniors directly. Revocation of consent will not affect the lawfulness of communications initiated prior to my withdrawal of consent. I further understand that by submitting this form, I am acknowledging and agreeing to receive communications on a recorded line for quality assurance and compliance purposes. Any charges or fees imposed by my telephone provider, including standard message or data rates, are my responsibility.

I affirm that the information I have provided is accurate and belongs to me. By providing this information, I release MAPDForSeniors from any liability resulting from misrepresentation, incorrect, or unauthorized submission of this form. This request and any resulting communication comply with federal and state telemarketing and Do-Not-Call laws, as well as the Telephone Consumer Protection Act (TCPA) and related FCC regulations.