Medicare Questionnaire

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Date of Birth* This field is required.
Date
Month
Day
Year
6
What is your biological sex?* This field is required.
7
How did you hear about us?* This field is required.
Google
NextDoor
Instagram
My Financial Advisor
Friend, Family Member, Neighbor
Other
8
Who is your Financial Advisor? * This field is required.
9
Are you currently retired?* This field is required.
Yes
No
10
Name of current employer* This field is required.
11
When do you plan on retiring?* This field is required.
i.e. in 60 days, 6 months or unsure
12
Are you currently Married?* This field is required.
Yes
No
13
Would you like us to review your spouses benefits as well?
YESNO
14
Spouse's name* This field is required.
First Name
Last Name
15
Spouse Radius Record ID
16
Spouse's Date of Birth* This field is required.
Date
Month
Day
Year
17
What is your Spouse's Biological Sex?* This field is required.
18
What is your spouse's email?We promise we won't spam them
example@example.com
19
What is your spouse's phone number?* This field is required.
Area Code
Phone Number
20
Is your spouse retired?* This field is required.
Yes
No
21
Name of your spouse's employer* This field is required.
22
When does your spouse plan to retire?* This field is required.
i.e. in 60 days, 6 months or unsure
23
What type of health coverage do you currently have?* This field is required.
Individual non-exchange plan (not state subsidized/non ACA)
On Exchange Plan (Exchange/ACA/state subsidized)
Employer Group Health Plan
Employer plan through my spouses employer
VA Coverage
Tri-care for life
Retiree Plan through previous employer or union
COBRA
COBRA through Spouse
Medi-cal
Cost sharing ministry plan (i.e. Medi-share)
No Health Insurance
Medicare due to disability
Medicare
24
What type of health coverage does your spouse have?* This field is required.
Individual non-exchange plan (not state subsidized/non ACA)
On Exchange Plan (Exchange/ACA/state subsidized)
Employer Group Health Plan
Employer plan through my spouses employer
VA Coverage
Tri-care for life
Retiree Plan through previous employer or union
COBRA
COBRA through Spouse
Medi-cal
Cost sharing ministry plan (i.e. Medi-share)
No Health Insurance
Medicare due to disability
Medicare
25
Name of current insurance company* This field is required.
i.e. Blue Shield
26
Name of your spouse's current insurance company* This field is required.
i.e. Blue Shield
27
Approximately how much does it cost for your share of health insurance?* This field is required.
28
Approximately how much does it cost for your spouse's share of health insurance?* This field is required.
29
Approximately when will you need to make a change, if any, to your health insurance?* This field is required.
30
Do you currently have Medicare Part A &/or Part B?* This field is required.
Part A and Part B
Part A only
Part B only
Neither
31
What is your Part A effective date?* This field is required.
Date
Month
Day
Year
32
What is your Part B effective date?* This field is required.
Date
Month
Day
Year
33
Does your spouse currently have Medicare Part A &/or Part B?* This field is required.
Part A and Part B
Part A only
Part B only
Neither
34
What is your spouse's Part A effective date?* This field is required.
Date
Year
Month
Day
35
What is your spouse's Part B effective date?* This field is required.
Date
Year
Month
Day
36
Are you currently drawing social security benefits of any kind?* This field is required.
Yes
No
37
Approximately when did you begin collecting social security benefits?* This field is required.
Date
Month
Day
Year
38
When do you want to begin collecting Social Security monthly retirement? (not medicare benefits)* This field is required.
When I begin Medicare
At full-retirement age
I want to delay Social Security payments as long as I can
Unsure
39
Is your spouse currently drawing social security benefits of any kind?* This field is required.
Yes
No
40
Approximately when did your spouse begin collecting social security benefits?* This field is required.
Date
Year
Month
Day
41
When does your spouse want to begin collecting Social Security monthly retirement? (not medicare benefits)* This field is required.
When they begin Medicare
At full-retirement age
They would like to delay Social Security payments as long as they can
Unsure
42
Are you interested in an HMO?* This field is required.
No
Yes
Unsure
43
Is your spouse interested in an HMO?* This field is required.
No
Yes
Unsure
44
Have you used any tobacco products in the last 12 months?* This field is required.
No
Yes
45
Has your spouse used any tobacco products in the last 12 months?* This field is required.
No
Yes
46
Have you been diagnosed or treated for any form of cancer, including skin cancer?* This field is required.
No
Yes
47
Has your spouse been diagnosed or treated for any form of cancer, including skin cancer?* This field is required.
No
Yes
48
Please list the names of your doctors and specialists
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Large
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Small
Ok
Ok
49
Please list the names of your spouse's doctors and specialists
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Ok
50
Are you currently taking any medications?* This field is required.
Yes
No
51
Please list the medications you are currently using. If you prefer, you can upload your Medication list at the end of the questionnaire. Include the name, quantity, frequency and dosage of the medication. (i.e. Eliquis 5 mg 2x daily)
52
Name of your preferred pharmacy
53
Is your spouse currently taking any medications?* This field is required.
Yes
No
54
Please list the medications your spouse is currently using. If you prefer, you can upload your Medication list at the end of the questionnaire. Include the name, quantity, frequency and dosage of the medication. (i.e. Eliquis 5 mg 2x daily)
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55
Name of your spouse's preferred pharmacy* This field is required.
56
What is your tax filing Status?
Married filing Jointly
Single
Married filing separately
Head of Household
Qualifying widow(er) with dependent child
57
(Married filing jointly) Social Security and Affordable Care Act plans base some insurance premiums on your Modified Adjusted Gross income. For most people, this is the same or similar as the Adjusted Gross Income. To the best of your ability, please estimate your Annual Joint Adjusted Gross Income for this year. Provide an estimated range if necessary.i.e. $100,000 - $150,000
58
(Married filing separately, HOH, QWD) Social Security and Affordable Care Act plans base some insurance premiums on your Modified Adjusted Gross income. For most people, this is the same or similar as the Adjusted Gross Income. To the best of your ability, please estimate your Annual Individual Adjusted Gross Income for this year. Provide an estimated range if necessary.i.e. $100,000 - $150,000
59
(Married filing separately, HOH, QWD) What is your spouse's individual Adjusted Gross Income? Provide estimated range if necessary.i.e. $100,000 - $150,000
60
(Single) Social Security and Affordable Care Act plans base some insurance premiums on your Modified Adjusted Gross income. For most people, this is the same as your Adjusted Gross Income. To the best of your ability, please estimate your Adjusted Gross Income for this year.i.e. $100,000 - $150,000
61
If you prefer, you can upload your medication list here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Cancelof
62
Are you interested in dental insurance?* This field is required.
YESNO
63
Who is your current dentist?
64
Enter anything additional you feel is relevant to your situation
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Ok
65
You will now be redirected to sign a form required by Center for Medicare and Medicaid Services. The form is called a Scope of Appointment (SOA), which allows you to select the products you would like discussed during our meeting. This is not an obligation to enroll into the products discuss. To proceed, select "I agree" then "Submit"
I agree
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