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Sam Carr and Innovative Solutions 4U, Inc. Present HEALTHPLANS-NC

North Carolina Health Plans - NC

Sam Carr, LUTCF Agent / Broker
Phone: (910) 278-5456 / Toll Free: (866) 609-6815 / Fax: (910) 845-9325

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We will strive to provide the most competitive pricing and may need to contact you via telephone in order to accurately provide you the best possible rates. Only one of our representatives will call to verify your quote or get any additional information needed.

Applicant's Name
Date of Birth	/ /

Part B Effective Date:	/ /
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Address:	City: State/Zip:
Telephone: (with area code)
Gender:
Is this person on Medicare due to disability?

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