Insurance Fillable Intake Form
To helps us better understand your exact needs & wants
Current Employer Name
Full legal names of everyone to be on the plan and those you list on your taxes as dependant. Please include everyone's- Height, Weight, and Date of Birth (example- Jane Doe, 5'5 135, 7/1/1974, John Doe 5'10 185 10/5/1972, Jonny Doe 5'6 125 1/15/2012).
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Tobacco Usage/Smoker for anyone needing coverage
Yes
No
To best serve your needs, please provide a detailed list of any pertinent medical history, including pre-existing conditions. For example- Jane Doe mentioned having a heart attack in 2014, and her husband, John Doe, was diagnosed with cancer in 2007 but is currently cancer-free. Please list all the details below
What is the Household Adjusted Gross income estimate for 2025 & 2026? (Your adjusted gross income (AGI) is your total (gross) income from all sources minus certain adjustments listed on Schedule 1 of Form 1040.taxable income)
What can you comfortably set aside per month for insurance? (what is your budget / range)
Current insurance carrier/plan/monthly premium Example- "United Healthcare, HMO or PPO" HSA Plan 12, $1,000 per month Example - "Currently on COBRA through my former employer $1800 per month"
What is your annual net income and your ENTIRE households Adjusted Gross Income? (To check for potential subsidy & Premium Tax Credits) Example- Jane Doe grosses $100k, but her Adjusted Gross Income for the household is $67k annually because of self employment & business deductions, etc
Please list ALL doctors, hospitals, and RX prescriptions you need to have covered in the network and RX formulary? (Doctor & Practice name, Hospital Name, and Prescription RX and Dosage information)
Have you ever worked with a fiduciary and a licensed insurance broker before? If so, what did you like about it and what do you think could have improved it?
Do you have any personal / family insurance objectives? (Please elaborate)
Are you familiar with Fee-Based Planning?
Yes
No
Do you worry about running out of money now or in retirement?
Yes
No
A plethora of plans exists in nearly every state. To help narrow down to realistic options, what is a realistic range can you comfortably set aside per month for insurance?
Please list several dates and times that work best for you to discuss findings with our team? (I.E. You are available Mon 6/12 Wed 6/14 Friday 6/16 at 2pm 4pm and 6pm) we will select one of your times and our team will send a calendar request to your email.
Submit
Should be Empty: