Additional Information Questionnaire
This form should only take 2-5 minutes to complete.
Name
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First Name
Last Name
How did you hear about our company? If it was a specific person, please give us that person's name (First and Last name), as we like to thank anyone who refers us.
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What is the current Health Insurance / Medicare situation you are looking to solve?
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When do you need to have a solution in place? Please keep in mind that all solutions are implemented on the 1st of the month; unfortunately, insurance carriers do not allow mid-month enrollments.
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What is the name of the plan(s) you are currently on? What are the premiums for these plans? - IF YOU ALREADY KNOW YOU ARE MOVING TO MEDICARE - SKIP THIS QUESTION
Which of the following options sounds closer to your ideal outcome?
I would prefer to pay higher premiums and have lower out-of-pocket costs
I would prefer lower premiums and have higher out-of-pocket costs
I am open to either of the above, I am just focused on getting the best value for my money
Please let us know if there is any additional information you would like to share with us. This may include specific prescriptions not previously mentioned, or any other health conditions that we should be aware of that will play a factor in customizing a solution for you.
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