Partnership Request Form

Georgia SHIP provides unbiased Medicare information and does not charge for any service. SHIPs do not partner with individual insurance agents or insurance companies.

Organization/Company Name (required)

Contact First Name (required)

Contact Last Name (required)

Address (required)

Address 2

City (required)

Zip Code (required)

State

County (required)

Phone

Email (required)

Confirm email (required)

Organization/Company Website (required)

How do you want to partner with Georgia SHIP?

Provide outreach materials to Georgia SHIP

Provide space(s) for Georgia SHIP counseling stations

Provide Georgia SHIP opportunities to present to my organization

Disseminate Georgia SHIP brochures and publications

Collaborate with Georgia SHIP on community and education events

Invite Georgia SHIP to provide training to my network and volunteers

Present information about my organization to Georgia SHIP

Other

(If 'Other' please specify):

Do you have an active license to sell insurance of any kind? (required)

Comments:

(Please Note: Do not include your Medicare, Social Security Number or Date of Birth)

Partnership Request Form

Call Us

Message

Mail

Hours