Legacy Health Insurance
641 Marketplace Drive #5
Waconia, MN 55387
info@LBCOnline.biz
TimTheMedicareMan.com
(952) 922-5677
Client Intake Form - Individual/family
Please complete this form at least 24 hours before your scheduled meeting. If this form is not completed, your appointment may be rescheduled.
Full Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Phone Number
*
E-mail
*
example@example.com
MNSure Username (If You Have One)
MNSure Password (If You Have One)
Address
*
Street Address
County
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address (If different from physical):
How did you hear about us?
*
Please Select
Internet Search
Radio
Newspaper
Mail
Referred by Friend/Family
Other
If referred by a friend, please let us know who so we can thank them!
Submit
Should be Empty: