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Client Info Assessment
This form allows me to properly prepare for our meeting and to research plans that fit your needs.
12
Questions
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1
What type of coverage do you need?
*
This field is required.
Individual Only
Individual & Child/Children
Individual & Spouse
Family Coverage
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2
How many dependents plus yourself
You + One Kid = 2
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3
Full Name
*
This field is required.
First Name
Last Name
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4
Spouse Full Name
*
This field is required.
First Name
Last Name
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5
Dependent One - Full Name
*
This field is required.
First Name
Last Name
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6
Dependent Two - Full Name
*
This field is required.
First Name
Last Name
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7
Dependent Three - Full Name
*
This field is required.
First Name
Last Name
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8
Dependent Four - Full Name
*
This field is required.
First Name
Last Name
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9
Dependent Five - Full Name
*
This field is required.
First Name
Last Name
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10
Dependent Six - Full Name
*
This field is required.
First Name
Last Name
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11
Your DOB
*
This field is required.
-
Date
Month
Day
Year
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12
Spouse - DOB
-
Date
Month
Day
Year
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13
Dependent One - DOB
-
Date
Month
Day
Year
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14
Dependent Two - DOB
-
Date
Month
Day
Year
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15
Dependent Three - DOB
-
Date
Month
Day
Year
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16
Dependent Four - DOB
-
Date
Month
Day
Year
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17
Dependent Five - DOB
-
Date
Month
Day
Year
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18
Dependent Six - DOB
-
Date
Month
Day
Year
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19
Your Gender
Please Select
Male
Female
Please Select
Please Select
Male
Female
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20
Spouse - Gender
Please Select
Male
Female
Please Select
Please Select
Male
Female
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21
Dependent One - Gender
Please Select
Male
Female
Please Select
Please Select
Male
Female
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22
Dependent Two - Gender
Please Select
Male
Female
Please Select
Please Select
Male
Female
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23
Dependent Three - Gender
Please Select
Male
Female
Please Select
Please Select
Male
Female
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24
Dependent Four - Gender
Please Select
Male
Female
Please Select
Please Select
Male
Female
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25
Dependent Five - Gender
Please Select
Male
Female
Please Select
Please Select
Male
Female
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26
Dependent Six - Gender
Please Select
Male
Female
Please Select
Please Select
Male
Female
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27
Phone Number
*
This field is required.
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28
E-mail
*
This field is required.
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29
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
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
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30
How Many People are on Your Taxes?
*
This field is required.
This is to check for savings on your premiums.
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31
Household Income Before Taxes?
*
This field is required.
Total household income including social security if you receive it.
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32
Do You File Jointly?
*
This field is required.
Must file jointly for subsidies. There are a few exceptions we can discuss. If you file single put single please.
Please Select
Joint
Separate
Single
Please Select
Please Select
Joint
Separate
Single
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33
List of Doctors
We use this to match the best plan for you.
Primary Care Doctor Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Dentist Name & Zip
Vision Doctor Name & Zip
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34
Spouse List of Doctors
We use this to match the best plan for you.
Primary Care Doctor Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Dentist Name & Zip
Vision Doctor Name & Zip
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35
Dependent One List of Doctors
We use this to match the best plan for you.
Primary Care Doctor Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Dentist Name & Zip
Vision Doctor Name & Zip
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36
Dependent Two List of Doctors
We use this to match the best plan for you.
Primary Care Doctor Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Dentist Name & Zip
Vision Doctor Name & Zip
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37
Dependent Three List of Doctors
We use this to match the best plan for you.
Primary Care Doctor Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Dentist Name & Zip
Vision Doctor Name & Zip
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38
Dependent Four List of Doctors
We use this to match the best plan for you.
Primary Care Doctor Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Dentist Name & Zip
Vision Doctor Name & Zip
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39
Dependent Five List of Doctors
We use this to match the best plan for you.
Primary Care Doctor Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Dentist Name & Zip
Vision Doctor Name & Zip
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40
Dependent Six List of Doctors
We use this to match the best plan for you.
Primary Care Doctor Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Specialist Name & Zip
Dentist Name & Zip
Vision Doctor Name & Zip
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41
List of Medications
We use this to match the best plan for you.
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
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42
Spouse List of Medications
We use this to match the best plan for you.
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
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43
Dependent One List of Medications
We use this to match the best plan for you.
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
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44
Dependent Two List of Medications
We use this to match the best plan for you.
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
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45
Dependent Three List of Medications
We use this to match the best plan for you.
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
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46
Dependent Four List of Medications
We use this to match the best plan for you.
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
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47
Dependent Five List of Medications
We use this to match the best plan for you.
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
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48
Dependent Six List of Medications
We use this to match the best plan for you.
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
Name, Dose, Quantity, Tab /Capsule
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