{"id":119,"date":"2026-02-25T21:28:33","date_gmt":"2026-02-25T21:28:33","guid":{"rendered":"https:\/\/agerhealth.com\/medicare\/?page_id=119"},"modified":"2026-02-26T14:52:39","modified_gmt":"2026-02-26T14:52:39","slug":"form","status":"publish","type":"page","link":"https:\/\/agerhealth.com\/medicare\/form\/","title":{"rendered":"Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"119\" class=\"elementor elementor-119\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6949329 e-flex e-con-boxed e-con e-parent\" data-id=\"6949329\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-456022d elementor-widget elementor-widget-html\" data-id=\"456022d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t\t<style>\r\n  .quote-form-container {\r\n    max-width: 500px;\r\n    margin: 60px auto;\r\n    background: #fff;\r\n    padding: 40px;\r\n    border-radius: 20px;\r\n    box-shadow: 0 10px 30px rgba(0, 0, 0, 0.1);\r\n    font-family: 'Segoe UI', sans-serif;\r\n    box-sizing: border-box;\r\n  }\r\n\r\n  .quote-form-container .progress-container {\r\n    display: flex;\r\n    align-items: center;\r\n    justify-content: space-between;\r\n    margin-bottom: 30px;\r\n  }\r\n\r\n  .quote-form-container .step-item {\r\n    background-color: #e1dcf9;\r\n    color: #6c5ce7;\r\n    font-weight: bold;\r\n    width: 36px;\r\n    height: 36px;\r\n    border-radius: 50%;\r\n    display: flex;\r\n    justify-content: center;\r\n    align-items: center;\r\n    transition: 0.3s;\r\n  }\r\n\r\n  .quote-form-container .step-item.active {\r\n    background-color: #6c5ce7;\r\n    color: white;\r\n  }\r\n\r\n  .quote-form-container .progress-bar {\r\n    flex-grow: 1;\r\n    height: 4px;\r\n    background-color: #e1dcf9;\r\n    margin: 0 5px;\r\n    border-radius: 2px;\r\n  }\r\n\r\n  .quote-form-container .progress-bar.active {\r\n    background-color: #6c5ce7;\r\n  }\r\n\r\n  .quote-form-container .step-title {\r\n    font-size: 22px;\r\n    font-weight: bold;\r\n    color: #333;\r\n    margin-bottom: 20px;\r\n    text-align: center;\r\n  }\r\n\r\n  .quote-form-container .form-input {\r\n    width: 100%;\r\n    padding: 14px;\r\n    border: 2px solid #ddd !important;\r\n    border-radius: 12px !important;\r\n    font-size: 16px;\r\n    margin-bottom: 20px;\r\n    box-sizing: border-box !important;\r\n    transition: border-color 0.3s;\r\n  }\r\n\r\n  .quote-form-container .form-input:focus {\r\n    border-color: #6c5ce7;\r\n    outline: none;\r\n  }\r\n\r\n  .quote-form-container .btn, .option-btn {\r\n    width: 100%;\r\n    padding: 14px;\r\n    border-radius: 12px;\r\n    font-size: 16px;\r\n    font-weight: bold;\r\n    margin: 8px 0;\r\n    cursor: pointer;\r\n    transition: 0.3s;\r\n  }\r\n\r\n  .quote-form-container .option-btn {\r\n    background: #fff;\r\n    border: 2px solid #6c5ce7;\r\n    color: #6c5ce7;\r\n  }\r\n\r\n  .quote-form-container .option-btn:hover {\r\n    background: #4A34A0;\r\n    color: #fff;\r\n  }\r\n\r\n  .quote-form-container .btn-primary {\r\n    background: #5F43B2;\r\n    color: white;\r\n    border: none;\r\n  }\r\n\r\n  .quote-form-container .btn-primary:hover {\r\n    background: #4A34A0;\r\n  }\r\n\r\n  .quote-form-container .btn-outline {\r\n    background: white;\r\n    color: #6c5ce7;\r\n    border: 2px solid #6c5ce7;\r\n  }\r\n\r\n  .quote-form-container .btn-outline:hover {\r\n    background: #f0eaff;\r\n  }\r\n\r\n  .quote-form-container .step {\r\n    display: none;\r\n  }\r\n\r\n  .quote-form-container .step.active {\r\n    display: block;\r\n  }\r\n\r\n  .quote-form-container .name-fields {\r\n    display: flex;\r\n    gap: 10px;\r\n    margin-bottom: 20px;\r\n  }\r\n\r\n  .quote-form-container .name-fields input {\r\n    flex: 1;\r\n  }\r\n\r\n  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!important;\r\n  }\r\n\r\n  @media (max-width: 600px) {\r\n    .quote-form-container .name-fields {\r\n      flex-direction: column;\r\n      gap: 0;\r\n    }\r\n  }\r\n  \r\n  \r\n  \/* Loader overlay *\/\r\n  .loader-overlay {\r\n    position: fixed;\r\n    top: 0;\r\n    left: 0;\r\n    width: 100%;\r\n    height: 100%;\r\n    background: rgba(255, 255, 255, 0.9);\r\n    display: flex;\r\n    justify-content: center;\r\n    align-items: center;\r\n    z-index: 9999;\r\n    display: none;\r\n    flex-direction: column;\r\n  }\r\n\r\n  .loader {\r\n    border: 6px solid #f3f3f3;\r\n    border-top: 6px solid #6c5ce7;\r\n    border-radius: 50%;\r\n    width: 60px;\r\n    height: 60px;\r\n    animation: spin 1s linear infinite;\r\n    margin-bottom: 15px;\r\n  }\r\n\r\n  @keyframes spin {\r\n    0% { transform: rotate(0deg); }\r\n    100% { transform: rotate(360deg); }\r\n  }\r\n\r\n  .loader-text {\r\n    font-size: 16px;\r\n    color: #333;\r\n    font-weight: bold;\r\n  }\r\n<\/style>\r\n\r\n<div class=\"loader-overlay\" id=\"loader\">\r\n  <div class=\"loader\"><\/div>\r\n  <div class=\"loader-text\">Processing your request...<\/div>\r\n<\/div>\r\n\r\n<div class=\"quote-form-container\">\r\n  <form id=\"quoteForm\" method=\"POST\" action=\"https:\/\/agerhealth.com\/medicare\/send_email.php\" class=\"quote-form\">\r\n\r\n\r\n    <!-- Hidden input for Medicare Status -->\r\n    <input type=\"hidden\" name=\"medicareStatus\" id=\"medicareStatus\" \/>\r\n\r\n    <!-- Progress Tracker with 5 steps -->\r\n    <div class=\"progress-container\">\r\n      <div class=\"step-item step-1 active\">1<\/div>\r\n      <div class=\"progress-bar bar-1\"><\/div>\r\n      <div class=\"step-item step-2\">2<\/div>\r\n      <div class=\"progress-bar bar-2\"><\/div>\r\n      <div class=\"step-item step-3\">3<\/div>\r\n      <div class=\"progress-bar bar-3\"><\/div>\r\n      <div class=\"step-item step-4\">4<\/div>\r\n      <div class=\"progress-bar bar-4\"><\/div>\r\n      <div class=\"step-item step-5\">5<\/div>\r\n    <\/div>\r\n\r\n    <!-- Step 1: Introduction -->\r\n    <div class=\"step step1 active\">\r\n      <h2 class=\"step-title\">Speak with a licensed Insurance Agent to explore your Medicare Advantage plan options and verify your enrollment eligibility<\/h2>\r\n      <h2 style=\"font-size:16px; text-align:center;\">New to Medicare, Aging into Medicare, Lost your Health Insurance, On Medicare but have recently moved?<\/h2>\r\n      <button type=\"button\" class=\"btn btn-primary\" onclick=\"showStep(2)\">Get Started<\/button>\r\n\r\n      <p class=\"tiny-text\">\r\n        Your eligibility for a Medicare Advantage plan that may include additional plan benefits depending on the time of year and your individual circumstances.\r\n      <\/p>\r\n    <\/div>\r\n\r\n    <!-- Step 2: Do you have Medicare Parts A and B? -->\r\n    <div class=\"step step2\">\r\n      <h2 class=\"step-title\">Do you currently have Medicare Parts A and B coverage?<\/h2>\r\n      <button type=\"button\" class=\"option-btn\" onclick=\"selectMedicareStatus('Yes')\">Yes<\/button>\r\n      <button type=\"button\" class=\"option-btn\" onclick=\"selectMedicareStatus('No')\">No<\/button>\r\n      <div class=\"skip-link\" onclick=\"skipMedicareStatus()\">Skip<\/div>\r\n    <\/div>\r\n\r\n    <!-- Phone Number Section Below Step 2 -->\r\n    <div class=\"phone-section\" id=\"phone-section-step2\" style=\"display: none;\">\r\n      <p><i class=\"fa fa-phone\"><\/i> <a href=\"tel:1-800-458-9569\">1-800-458-9569 (TTY 711)<\/a> <br\/> Speak with a licensed insurance agent<\/p>\r\n    <\/div>\r\n\r\n    <!-- Step 3: Date of Birth -->\r\n    <div class=\"step step3\">\r\n      <h2 class=\"step-title\">When were you Born? (Optional)<\/h2>\r\n\r\n      <select name=\"dobMonth\" class=\"form-input\" id=\"dobMonth\">\r\n        <option value=\"\">Month<\/option>\r\n        <option value=\"01\">January<\/option>\r\n        <option value=\"02\">February<\/option>\r\n        <option value=\"03\">March<\/option>\r\n        <option value=\"04\">April<\/option>\r\n        <option value=\"05\">May<\/option>\r\n        <option value=\"06\">June<\/option>\r\n        <option value=\"07\">July<\/option>\r\n        <option value=\"08\">August<\/option>\r\n        <option value=\"09\">September<\/option>\r\n        <option value=\"10\">October<\/option>\r\n        <option value=\"11\">November<\/option>\r\n        <option value=\"12\">December<\/option>\r\n      <\/select>\r\n\r\n      <select name=\"dobYear\" class=\"form-input\" id=\"dobYear\">\r\n        <option value=\"\">Year<\/option>\r\n        <option value=\"1920\">1920<\/option>\r\n    <option value=\"1921\">1921<\/option>\r\n    <option value=\"1922\">1922<\/option>\r\n    <option value=\"1923\">1923<\/option>\r\n    <option value=\"1924\">1924<\/option>\r\n    <option value=\"1925\">1925<\/option>\r\n    <option value=\"1926\">1926<\/option>\r\n    <option value=\"1927\">1927<\/option>\r\n    <option value=\"1928\">1928<\/option>\r\n    <option value=\"1929\">1929<\/option>\r\n    <option value=\"1930\">1930<\/option>\r\n    <option value=\"1931\">1931<\/option>\r\n    <option value=\"1932\">1932<\/option>\r\n    <option value=\"1933\">1933<\/option>\r\n    <option value=\"1934\">1934<\/option>\r\n    <option value=\"1935\">1935<\/option>\r\n    <option value=\"1936\">1936<\/option>\r\n    <option value=\"1937\">1937<\/option>\r\n    <option value=\"1938\">1938<\/option>\r\n    <option value=\"1939\">1939<\/option>\r\n    <option value=\"1940\">1940<\/option>\r\n    <option value=\"1941\">1941<\/option>\r\n    <option value=\"1942\">1942<\/option>\r\n    <option value=\"1943\">1943<\/option>\r\n    <option value=\"1944\">1944<\/option>\r\n    <option value=\"1945\">1945<\/option>\r\n    <option value=\"1946\">1946<\/option>\r\n    <option value=\"1947\">1947<\/option>\r\n    <option value=\"1948\">1948<\/option>\r\n    <option value=\"1949\">1949<\/option>\r\n    <option value=\"1950\">1950<\/option>\r\n    <option value=\"1951\">1951<\/option>\r\n    <option value=\"1952\">1952<\/option>\r\n    <option value=\"1953\">1953<\/option>\r\n    <option value=\"1954\">1954<\/option>\r\n    <option value=\"1955\">1955<\/option>\r\n    <option value=\"1956\">1956<\/option>\r\n    <option value=\"1957\">1957<\/option>\r\n    <option value=\"1958\">1958<\/option>\r\n    <option value=\"1959\">1959<\/option>\r\n    <option value=\"1960\">1960<\/option>\r\n    <option value=\"1961\">1961<\/option>\r\n    <option value=\"1962\">1962<\/option>\r\n    <option value=\"1963\">1963<\/option>\r\n    <option value=\"1964\">1964<\/option>\r\n    <option value=\"1965\">1965<\/option>\r\n    <option value=\"1966\">1966<\/option>\r\n    <option value=\"1967\">1967<\/option>\r\n    <option value=\"1968\">1968<\/option>\r\n    <option value=\"1969\">1969<\/option>\r\n    <option value=\"1970\">1970<\/option>\r\n    <option value=\"1971\">1971<\/option>\r\n    <option value=\"1972\">1972<\/option>\r\n    <option value=\"1973\">1973<\/option>\r\n    <option value=\"1974\">1974<\/option>\r\n    <option value=\"1975\">1975<\/option>\r\n    <option value=\"1976\">1976<\/option>\r\n    <option value=\"1977\">1977<\/option>\r\n    <option value=\"1978\">1978<\/option>\r\n    <option value=\"1979\">1979<\/option>\r\n    <option value=\"1980\">1980<\/option>\r\n    <option value=\"1981\">1981<\/option>\r\n    <option value=\"1982\">1982<\/option>\r\n    <option value=\"1983\">1983<\/option>\r\n    <option value=\"1984\">1984<\/option>\r\n    <option value=\"1985\">1985<\/option>\r\n    <option value=\"1986\">1986<\/option>\r\n    <option value=\"1987\">1987<\/option>\r\n    <option value=\"1988\">1988<\/option>\r\n    <option value=\"1989\">1989<\/option>\r\n    <option value=\"1990\">1990<\/option>\r\n    <option value=\"1991\">1991<\/option>\r\n    <option value=\"1992\">1992<\/option>\r\n    <option value=\"1993\">1993<\/option>\r\n    <option value=\"1994\">1994<\/option>\r\n    <option value=\"1995\">1995<\/option>\r\n    <option value=\"1996\">1996<\/option>\r\n    <option value=\"1997\">1997<\/option>\r\n    <option value=\"1998\">1998<\/option>\r\n    <option value=\"1999\">1999<\/option>\r\n    <option value=\"2000\">2000<\/option>\r\n    <option value=\"2001\">2001<\/option>\r\n    <option value=\"2002\">2002<\/option>\r\n    <option value=\"2003\">2003<\/option>\r\n    <option value=\"2004\">2004<\/option>\r\n    <option value=\"2005\">2005<\/option>\r\n    <option value=\"2006\">2006<\/option>\r\n    <option value=\"2007\">2007<\/option>\r\n    <option value=\"2008\">2008<\/option>\r\n    <option value=\"2009\">2009<\/option>\r\n    <option value=\"2010\">2010<\/option>\r\n    <option value=\"2011\">2011<\/option>\r\n    <option value=\"2012\">2012<\/option>\r\n    <option value=\"2013\">2013<\/option>\r\n    <option value=\"2014\">2014<\/option>\r\n    <option value=\"2015\">2015<\/option>\r\n    <option value=\"2016\">2016<\/option>\r\n    <option value=\"2017\">2017<\/option>\r\n    <option value=\"2018\">2018<\/option>\r\n    <option value=\"2019\">2019<\/option>\r\n    <option value=\"2020\">2020<\/option>\r\n    <option value=\"2021\">2021<\/option>\r\n      <\/select>\r\n\r\n      <button type=\"button\" class=\"btn btn-outline back-btn\" onclick=\"goBack()\">Back<\/button>\r\n      <button type=\"button\" class=\"btn btn-primary next-btn\" id=\"nextDOB\" onclick=\"showStep(4)\">Next<\/button>\r\n    <\/div>\r\n\r\n    <!-- Phone Number Section Below Step 3 -->\r\n    <div class=\"phone-section\" id=\"phone-section-step3\" style=\"display: none;\">\r\n      <p><i class=\"fa fa-phone\"><\/i> <a href=\"tel:+18004589569\">1-800-458-9569\u202c (TTY 711)<\/a> <br\/> Speak with a licensed insurance agent<\/p>\r\n    <\/div>\r\n\r\n    <!-- Step 4: ZIP Code -->\r\n    <div class=\"step step4\">\r\n      <h2 class=\"step-title\">What zip code do you live in? (Optional)<\/h2>\r\n      <input type=\"text\" name=\"zipcode\" id=\"zipcode\" class=\"form-input input-zip\" maxlength=\"5\" oninput=\"checkZip()\" \/>\r\n\r\n      <button type=\"button\" class=\"btn btn-outline back-btn\" onclick=\"goBack()\">Back<\/button>\r\n      <button type=\"button\" class=\"btn btn-primary next-btn\" id=\"nextZIP\" onclick=\"showStep(5)\">Next<\/button>\r\n\r\n      <p class=\"tiny-text\">This question is not mandatory, and it is not necessary to proceed for information about Medicare Advantage plans.<\/p>\r\n    <\/div>\r\n\r\n    <!-- Phone Number Section Below Step 4 -->\r\n    <div class=\"phone-section\" id=\"phone-section-step4\" style=\"display: none;\">\r\n      <p><i class=\"fa fa-phone\"><\/i> <a href=\"tel:+18004589569\">1-800-458-9569 (TTY 711)<\/a> <br\/> Speak with a licensed insurance agent<\/p>\r\n    <\/div>\r\n\r\n    <!-- Step 5: Contact Information -->\r\n    <div class=\"step step5\">\r\n      <h2 class=\"step-title\">Contact Information<\/h2>\r\n\r\n      <div class=\"name-fields\">\r\n        <input type=\"text\" name=\"fname\" placeholder=\"First Name\" required class=\"form-input input-first-name\" \/>\r\n        <input type=\"text\" name=\"lname\" placeholder=\"Last Name\" required class=\"form-input input-last-name\" \/>\r\n      <\/div>\r\n\r\n      <input type=\"tel\" name=\"phone\" placeholder=\"(xxx) xxx-xxxx\" maxlength=\"14\" inputmode=\"numeric\"\r\n        oninput=\"formatPhoneNumber(this)\" required class=\"form-input input-phone\" \/>\r\n\r\n      <button type=\"submit\" class=\"btn btn-primary submit-btn\">Submit<\/button>\r\n\r\n      <p class=\"consent-text\">\r\n       By clicking 'Submit', you represent that you are 18+ years of age and agree to the <a href=\"https:\/\/agerhealth.com\/medicare\/privacy-policy\/\" style=\"color:#4A34A0; text-decoration:none; font-size:12;\">Privacy Policy\r\n       <\/a>and  <a href=\"https:\/\/agerhealth.com\/medicare\/terms-and-conditions\/\" style=\"color:#4A34A0; text-decoration:none; font-size:12;\"> Terms & Conditions.<\/a> By selecting the above checkbox, you provide your express written consent for a representative of agerhealth.com to contact you at the number you provided, even if it is listed on the National Do Not Call Registry. You agree to receive telephonic sales and marketing calls and text messages using an automated system for dialing or selecting telephone numbers, AI generative voice calls, prerecorded messages, or emails regarding products or services, including Medicare Supplement, Medicare Advantage, Prescription Drug insurance plans, and other health-related services. Calls and messages are for marketing purposes, and cellular charges may apply. Your consent does not impact your eligibility to enroll in a plan, and you can change your permission preferences at any time by contacting Agerhealth.com. You understand that this request was initiated by you and is an unscheduled contact request, constituting your affirmative consent to be contacted in compliance with all federal and state telemarketing and Do-Not-Call laws. Licensed Sales Agents are not connected with or endorsed by the U.S. government or the federal Medicare program. To receive quotes without providing consent, please call 1-800-458-9569 (TTY 711). Please note this is a solicitation for insurance.\r\n      <\/p>\r\n\r\n      <div class=\"skip-link\" onclick=\"goBack()\">Back<\/div>\r\n    <\/div>\r\n\r\n    <!-- Phone Number Section Below Step 5 -->\r\n    <div class=\"phone-section\" id=\"phone-section-step5\" style=\"display: none;\">\r\n      <p><i class=\"fa fa-phone\"><\/i> <a href=\"tel:+18004589569\">1-800-458-9569 (TTY 711)<\/a> <br\/> Speak with a licensed insurance agent<\/p>\r\n    <\/div>\r\n\r\n    <!-- Hidden inputs -->\r\n    <input type=\"hidden\" name=\"age65plus\" id=\"age65plus\" \/>\r\n    <input type=\"hidden\" name=\"gender\" id=\"gender\" class=\"input-gender\" \/>\r\n  <\/form>\r\n<\/div>\r\n\r\n<script>\r\n  let currentStep = 1;\r\n\r\n  function showStep(stepNum) {\r\n    document.querySelectorAll('.step').forEach(step => step.classList.remove('active'));\r\n    document.querySelector('.step' + stepNum).classList.add('active');\r\n    currentStep = stepNum;\r\n\r\n    \/\/ Show the phone section below each step (but only once per step)\r\n    document.querySelectorAll('.phone-section').forEach(section => section.style.display = 'none');\r\n    document.getElementById('phone-section-step' + stepNum).style.display = 'block';\r\n\r\n    \/\/ Update progress bar and dots\r\n    for (let i = 1; 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\/\/ Hide loader on error\r\n    });\r\n\r\n  });\r\n<\/script>\r\n\r\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Processing your request&#8230; 1 2 3 4 5 Speak with a licensed Insurance Agent to explore your Medicare Advantage plan options and verify your enrollment eligibility New to Medicare, Aging into Medicare, Lost your Health Insurance, On Medicare but have recently moved? Get Started Your eligibility for a Medicare Advantage plan that may include additional [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-119","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/agerhealth.com\/medicare\/wp-json\/wp\/v2\/pages\/119","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/agerhealth.com\/medicare\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/agerhealth.com\/medicare\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/agerhealth.com\/medicare\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/agerhealth.com\/medicare\/wp-json\/wp\/v2\/comments?post=119"}],"version-history":[{"count":40,"href":"https:\/\/agerhealth.com\/medicare\/wp-json\/wp\/v2\/pages\/119\/revisions"}],"predecessor-version":[{"id":266,"href":"https:\/\/agerhealth.com\/medicare\/wp-json\/wp\/v2\/pages\/119\/revisions\/266"}],"wp:attachment":[{"href":"https:\/\/agerhealth.com\/medicare\/wp-json\/wp\/v2\/media?parent=119"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}