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To provide you with the best possible health insurance solutions, it's essential that we understand your unique needs and circumstances. Accurate information about your current coverage, budget, and medical treatment frequency allows us to tailor our recommendations and ensure you receive the most suitable and cost-effective plan. Your detailed responses will help us protect your lifestyle and address your specific health insurance requirements effectively.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What types of insurance do you currently have?
*
Major Medical Private Health Coverage
Group Coverage through my employer
Marketplace (Affordable Care Act)
Medicaid
Medicare (Supplement or Advantage)
Life Insurance
Dental
Vision
Other
I do not currently have coverage
I would like to learn about the following:
*
Private Health Insurance Options
Whole Life Policies that build cash value
Term Life Policies with smaller premiums
Marketplace Plans (Affordable Care Act)
Group Insurance for my small business
Accident & Sickness Policies to help cover my deductible
Medicare Advantage Plans
Medicare Supplement Plans
Dental Coverage
Vision Coverage
Other
If you chose OTHER, please explain below:
Date you would like coverage to start
*
-
Month
-
Day
Year
Date
Please select any of the following that has occurred within the last 60 Days:
*
Loss of health coverage (including Medicaid or Children's Health Insurance Program (CHIP) coverage)
Moved to a new address
Change in Marital Status (Marriage, Divorce-causing loss of coverage)
Change of household size (new child, adoption, foster care, court order)
Change of income that may qualify you for coverage under the federal poverty level (FPL)
Gaining status as a citizen, national, or lawfully present immigrant
Released from incarceration
Other
None of the above
If you chose OTHER, please explain below:
Please indicate how frequently you or your family members typically visit healthcare providers or receive medical treatment
Please Select
Weekly
Monthly
Semi-Annually
Annually
Do you (or anyone applying for coverage) have any medical conditions that need to be taken into consideration?
*
Confidentiality Notice: The information you provide on this form, including details about any medical conditions, is highly confidential and will not be shared with anyone without your explicit consent. While you are under no obligation to share this information, please note that if we are unaware of any medical conditions, we cannot guarantee that the plan will fully cover your needs. Sharing these details helps us find the best plan for you.
Employer
*
Household size (everyone on tax return)
*
Expected adjusted gross annual household income for this year? (after taxes)
*
Providing your expected adjusted gross annual household income helps us determine if you qualify for specific health insurance plans and subsidies based on your income. Accurate information is crucial to ensure you receive the best options and benefits available to you.
Please provide an estimate of what you are comfortable spending on health insurance each month.
This will help tailor solutions to fit your financial needs.
Do you currently have employer coverage?
*
Yes
No
What would your ideal health insurance plan look like? What specific needs or preferences do you have that I can assist with to ensure you get the best coverage possible?
If something unexpected were to happen to you, do you have sufficient insurance coverage to ensure you and your family can maintain your current lifestyle?
Family Members/Dependents: (If you are adding a member to your policy, the Insurance Company WILL require the following information below as well as a Social Security Number for each person of file.)
Doctors and Medications: You do NOT need to list the Doctor for each listed Medication/Prescription as these are separate columns!
Is there anything else you would like to add or anything specific I should know to help you find the best health insurance solution?
Authorization and Consent: I give permission for Jennifer Peterson (Insurance Broker) to research and follow up with different options for you based on the above information you provided?
*
Today's Date
*
-
Month
-
Day
Year
Date
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