Tentative date of appointment with a representative of Buckley Insurance Group is December 07, 2025. After submitting this form you will be able to schedule an appointment on a date and time of your choosing but no sooner that two days from today.
By submitting this form, you agree to meet in person or remotely with a Licensed Sales Representative to discuss the products checked above. The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do not work directly for the federal government. Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential.