Benefit and Care Health Insurance Intake Form

Benefit and Care Solutions Insurance Quote Request

Benefit and Care Solutions Information Submission and Consent Form. This is not issuance of health insurance. You must review and submit a formal application with a LIVE Health Insurance Agent to determine your needs and eligibility. NOTE: No Fees are collected from the applicant.
Age
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Terms & Conditions

Please Click to Agree

Dependent or Spouse Info

If none, click ONLY NEEDED ONE IF UNDER 65 NEXT.
Spouse or Dependent 1 Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Tobacco?
Dependent 2 Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Tobacco?
Please list any dependents with any medical conditions and/or prescribed medication(s). List all prescribed medication taken, how often, for what reason, include current medical condition or medical history: including heart, stroke, cancer, injuries, ongoing treatments or treatment recommendations pending.

General Health Questions

Please answer to the best of your capability for accuracy in determining the best plan for you.
Are currently insured by a major medical plan, shared health plan, or Obamacare?
List your current insurance providers name, (if applicable):
Provide your effective date needed by:
Are you or any person in your household pregnant or wanting to get pregnant?

List of Medical Providers and Specialist
What filing status do you use for taxes?
Please provide the name of the person who referred you, (if applicable).
Please click link and read consent before signing below. By clicking and signing below you are acknowleging the information on your intake form is correct and giving Benefit and Care Solutions permission to act as your agent

https://www.dropbox.com/scl/fi/mii725ub3on63ds6ka01v/ACA-CMS-Consent.pdf?rlkey=eh9hvqkgl6z4ya47m2urq2zrs&st=wz4pkpko&dl=0
Signature
Should be Empty:

Benefit and Care Solutions Insurance Quote Request