PacificSource Servicing Agent Assignment

Please complete the form below to assign us as servicing agent on your PacificSource Advantage policy. By completing this form, you allow us to get information about your Medicare Advantage plan. You acknowledge you are aware that we are not employed by PacificSource Medicare. Assigning us will replace your prior producer, if any existed.

This change will remain in effect until you let the plan know of a new change in writing. We appreciate the opportunity to be of service to you.