ROC Insurance Services

Independent - Objective - Personal

Our seasoned team understands how insurance affects you. From Medicare and the new landscape of the Affordable Care Act to strategies for business owners, we offer a personal approach and expertise to the Rochester area.

Kathy Coler

Kathy Coler

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Scope of Appointment - Coler

EPIC - Elderly Pharmaceutical Coverage Application

Aetna Optional Supplemental Benefit application

Pre-Appointment Profile

Your Name *
Your Name
Date of Birth *
Date of Birth
Medicare Part A Effective Date
Medicare Part A Effective Date
Medicare Part B Effective Date
Medicare Part B Effective Date
Home Phone
Home Phone
Cell Pone
Cell Pone
Please include dosage and frequency
CLIENT INFORMATION: Client 1
Choose applicable statement and note current plan below, if known.
Choose applicable statement and note current plan below, if known.
Health Status
Income for Part B Premium (Last 2 years' tax returns)
2018 return: Adjusted gross + tax exempt interest over $85,000 Single or $175,000 Joint
2017 return: Adjusted gross + tax exempt interest over $85,000 Single or $175,000 Joint
CLIENT INFORMATION: Client 2
Choose applicable statement and note current plan below, if known.
Choose applicable statement and note current plan below, if known.
Health Status
I am authorizing ROC Insurance services to use the Medicare.gov pharmacy tool on my behalf to help project my prescription drug cost. This will include the registration process of establishing a user name and password; and will carry over from year to year, unless otherwise revoked.

ROC Insurance Services  •  (585) 413 - 0483  -  2000 Winton Rd. S.  Suite 100 Rochester NY 14618

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