EIG | New Client Intake Form

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Image Field
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Name
First Name
Last Name
4
Mailing Address
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
Phone Number
Please enter a valid phone number.
6
Email
example@example.com
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Birth Date
Month
Day
Year
8
MEDICARE # The Red White and Blue Card
9
How familiar are you with Medicare?
Please Select
Please Select
Not familiar
A little familiar, but I don't know where to start
I have a pretty good idea
Fun fact: Harry Truman was the first recipient of a Medicare card!
10
Tell me about your current health insurance
Please Select
Please Select
I have coverage through my employer/union
I have an individual plan through the marketplace
Original Medicare (Part A and B)
I'm already on Medicare Advantage plan
I'm on COBRA
I have Medicaid
I don't have health Insurance
Other
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What is your current Medicare Advantage Plan name?Include Medicaid if you have extra help.
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Do any of these apply to you?
Please Select
Please Select
None of these apply
Federal Retirement Benefits
State Retirement Benefits
State Teachers Retirement System
TRICARE
CA (Veterans Affairs)
13
What's your preferred pharmacy?
Include the location cross street
14
Let's take a look at your current prescriptions.

Please have your prescription bottles ready so we know exactly which medications you take. (Spelling, dosage and frequency are important!)
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Please enter your current prescription medications: Prescription Name - Dosage - Quantity.Click ADD Row to add more drugs
16
Tell us about your Doctors, Hospitals and Clinics.To provide plan options in your area, we’ll need some info on your doctors, preferred hospital(s) and clinics to verify their network status. List of your Doctors and specialist:
Please Select
Please Select
Primary Care Doctor – Senior care specialist
Cardiologist – Heart health
Endocrinologist – Diabetes & hormones
Pulmonologist – Lungs & breathing
Nephrologist – Kidney health
Neurologist – Brain & nerves
Rheumatologist – Arthritis & joints
Oncologist – Cancer care
Urologist – Urinary & prostate
Ophthalmologist – Eyes & vision
Audiologist – Hearing
Podiatrist – Feet & mobility
Psychiatrist – Mental health
Dentist - Teeth
Optometrist - Reading Glasses
Select your healthcare specialists
Name
Please Select
Please Select
Primary Care Doctor – Senior care specialist
Cardiologist – Heart health
Endocrinologist – Diabetes & hormones
Pulmonologist – Lungs & breathing
Nephrologist – Kidney health
Neurologist – Brain & nerves
Rheumatologist – Arthritis & joints
Oncologist – Cancer care
Urologist – Urinary & prostate
Ophthalmologist – Eyes & vision
Audiologist – Hearing
Podiatrist – Feet & mobility
Psychiatrist – Mental health
Dentist - Teeth
Optometrist - Reading Glasses
Name
Please Select
Please Select
Primary Care Doctor – Senior care specialist
Cardiologist – Heart health
Endocrinologist – Diabetes & hormones
Pulmonologist – Lungs & breathing
Nephrologist – Kidney health
Neurologist – Brain & nerves
Rheumatologist – Arthritis & joints
Oncologist – Cancer care
Urologist – Urinary & prostate
Ophthalmologist – Eyes & vision
Audiologist – Hearing
Podiatrist – Feet & mobility
Psychiatrist – Mental health
Dentist - Teeth
Optometrist - Reading Glasses
Name
Please Select
Please Select
Primary Care Doctor – Senior care specialist
Cardiologist – Heart health
Endocrinologist – Diabetes & hormones
Pulmonologist – Lungs & breathing
Nephrologist – Kidney health
Neurologist – Brain & nerves
Rheumatologist – Arthritis & joints
Oncologist – Cancer care
Urologist – Urinary & prostate
Ophthalmologist – Eyes & vision
Audiologist – Hearing
Podiatrist – Feet & mobility
Psychiatrist – Mental health
Dentist - Teeth
Optometrist - Reading Glasses
Name
17
List any Chronic Conditions you have.
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Ok
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Tell us about your Doctors, Hospitals and Clinics.To provide plan options in your area, we’ll need some info on your doctors, preferred hospital(s) and clinics to verify their network status. List of your Doctors and specialist:
Please Select
Please Select
Primary Care Doctor – Senior care specialist
Cardiologist – Heart health
Endocrinologist – Diabetes & hormones
Pulmonologist – Lungs & breathing
Nephrologist – Kidney health
Neurologist – Brain & nerves
Rheumatologist – Arthritis & joints
Oncologist – Cancer care
Urologist – Urinary & prostate
Ophthalmologist – Eyes & vision
Audiologist – Hearing
Podiatrist – Feet & mobility
Psychiatrist – Mental health
Dentist - Teeth
Optometrist - Reading Glasses
Select your healthcare specialists
Name
Please Select
Please Select
Primary Care Doctor – Senior care specialist
Cardiologist – Heart health
Endocrinologist – Diabetes & hormones
Pulmonologist – Lungs & breathing
Nephrologist – Kidney health
Neurologist – Brain & nerves
Rheumatologist – Arthritis & joints
Oncologist – Cancer care
Urologist – Urinary & prostate
Ophthalmologist – Eyes & vision
Audiologist – Hearing
Podiatrist – Feet & mobility
Psychiatrist – Mental health
Dentist - Teeth
Optometrist - Reading Glasses
Name
Please Select
Please Select
Primary Care Doctor – Senior care specialist
Cardiologist – Heart health
Endocrinologist – Diabetes & hormones
Pulmonologist – Lungs & breathing
Nephrologist – Kidney health
Neurologist – Brain & nerves
Rheumatologist – Arthritis & joints
Oncologist – Cancer care
Urologist – Urinary & prostate
Ophthalmologist – Eyes & vision
Audiologist – Hearing
Podiatrist – Feet & mobility
Psychiatrist – Mental health
Dentist - Teeth
Optometrist - Reading Glasses
Name
Please Select
Please Select
Primary Care Doctor – Senior care specialist
Cardiologist – Heart health
Endocrinologist – Diabetes & hormones
Pulmonologist – Lungs & breathing
Nephrologist – Kidney health
Neurologist – Brain & nerves
Rheumatologist – Arthritis & joints
Oncologist – Cancer care
Urologist – Urinary & prostate
Ophthalmologist – Eyes & vision
Audiologist – Hearing
Podiatrist – Feet & mobility
Psychiatrist – Mental health
Dentist - Teeth
Optometrist - Reading Glasses
Name
19
Tell us about your Doctors, Hospitals and Clinics.To provide plan options in your area, we’ll need some info on your doctors, preferred hospital(s) and clinics to verify their network status. List of your Doctors and specialist:
Please Select
Please Select
Primary Care Doctor – Senior care specialist
Cardiologist – Heart health
Endocrinologist – Diabetes & hormones
Pulmonologist – Lungs & breathing
Nephrologist – Kidney health
Neurologist – Brain & nerves
Rheumatologist – Arthritis & joints
Oncologist – Cancer care
Urologist – Urinary & prostate
Ophthalmologist – Eyes & vision
Audiologist – Hearing
Podiatrist – Feet & mobility
Psychiatrist – Mental health
Dentist - Teeth
Optometrist - Reading Glasses
Select your healthcare specialists
Name
Please Select
Please Select
Primary Care Doctor – Senior care specialist
Cardiologist – Heart health
Endocrinologist – Diabetes & hormones
Pulmonologist – Lungs & breathing
Nephrologist – Kidney health
Neurologist – Brain & nerves
Rheumatologist – Arthritis & joints
Oncologist – Cancer care
Urologist – Urinary & prostate
Ophthalmologist – Eyes & vision
Audiologist – Hearing
Podiatrist – Feet & mobility
Psychiatrist – Mental health
Dentist - Teeth
Optometrist - Reading Glasses
Name
Please Select
Please Select
Primary Care Doctor – Senior care specialist
Cardiologist – Heart health
Endocrinologist – Diabetes & hormones
Pulmonologist – Lungs & breathing
Nephrologist – Kidney health
Neurologist – Brain & nerves
Rheumatologist – Arthritis & joints
Oncologist – Cancer care
Urologist – Urinary & prostate
Ophthalmologist – Eyes & vision
Audiologist – Hearing
Podiatrist – Feet & mobility
Psychiatrist – Mental health
Dentist - Teeth
Optometrist - Reading Glasses
Name
Please Select
Please Select
Primary Care Doctor – Senior care specialist
Cardiologist – Heart health
Endocrinologist – Diabetes & hormones
Pulmonologist – Lungs & breathing
Nephrologist – Kidney health
Neurologist – Brain & nerves
Rheumatologist – Arthritis & joints
Oncologist – Cancer care
Urologist – Urinary & prostate
Ophthalmologist – Eyes & vision
Audiologist – Hearing
Podiatrist – Feet & mobility
Psychiatrist – Mental health
Dentist - Teeth
Optometrist - Reading Glasses
Name
20
Image Field
21
Beneficiary or Authorized Representative SIGNATUREUse your mouse or finger to draw your signature inside the box.
22
Signature Date
Date
Month
Day
Year
23
What is the best day and time for our Licensed Agent to call you?MEDICARE Plan Benefits Review
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