BOR - BROKER OF RECORD

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By completing this online form on our secure server, it will save us both time from gathering all of your contact information over the phone. Once we receive your form, a member from our team will be in contact with you ASAP to take the next step.

*** IMPORTANT ***

By clicking the "Submit" button on this secure form, I authorize someone from the MedicareSTOP.com Team to contact me via phone and/or email and assist me with completing the Broker of Record (BOR) form.