The Incomologists®

We've Got You Covered
Estimated completion time 2-3 minutes.

Hi!

We have been in your shoes and understand how overwhelming this process can be.

We are independent professionals who are here to serve as your guide and advocate.

Please complete and submit the form below so that we can reach out with additional information. We're all veterans of countless annual HIPAA modules, and will absolutely never sell or use your information for anything other than what you contacted us for.

We look forward to serving you!
Full Name:*

First NameLast Name
How Can We Help?

Health InsuranceMalpractice InsuranceTrue Own Occupation Disability InsuranceLife InsuranceRetirement Account Setup/MaintenanceEducation/Support for Transition to 1099
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Email Address:*
example@example.com
Phone Number:
Please enter a valid phone number.
State of Residence:
Health Insurance
Zip Code of Residence:
Ages of people that need coverage
Medications taken by anyone who needs coverage:
Providers and specialists needed
Malpractice Insurance
City and State of Practice
Number of practice hours per week
Requested limits of liability
Optional information
True Own Occupation Disability Insurance
Profession
DOB

MonthDayYear
Date
Sex

MaleFemale
Do you currently spend the majority of your time working W2 or 1099?

W21099
What was your gross (before taxes) annual W2 income Last Year?
Do you plan to transition to majority 1099 within the next 6 months?

YesNo
When did/will you start working 1099?
Do you have a signed contract?

YesNo
How much do/will you make in your 1099 position?
How long is the contract for?
What is the hourly rate?
Do you have a guaranteed number of hours per week?
Please list any facilities that you currently work at in a W2 position, even per diem.
Do you currently have disability insurance? If yes, how much does it cover?
Height/Weight*
Current Prescription Meds
Please list any medical conditions, specialists that you see, or recent injuries or surgeries
Life Insurance
Additional information you would like to provide on the coverage that you are looking for etc.
Life Insurance
DOB

MonthDayYear
Date
Sex

MaleFemale
Height/Weight*
Current Prescription Meds
Please list any medical conditions, specialists that you see, or recent injuries or surgeries
Additional information you would like to provide on the coverage that you are looking for etc.
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We are veterans of countless annual HIPAA trainings, and take your privacy as seriously as if it were our own. By checking this box you authorize us to use this information for the purposes that you contacted us for, and release us from liability should it be accidentally viewed by others. We will NEVER sell your personal information.
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We've Got You Covered

Health Insurance

Malpractice Insurance

True Own Occupation Disability Insurance

Life Insurance

Life Insurance