General Information
Full name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Contact Method
Please Select
Call
Text
Email
Which type of insurance do you need?
Please Select
Medicare
Ambetter(Marketplace Health Insurance)
Life Insurance
Back
Next
Medicare Details
Medicare Questions
Are you currently on Medicare?
*
Yes
No
Do you have Medicare Part A and B active?
*
Yes
No
Are you turning 65 soon?
Yes
No
Medicare Beneficiary ID(from your red, white, and blue card)
Effective Date of Part A
-
Month
-
Day
Year
Date
Effective Date of Part B
-
Month
-
Day
Year
Date
Do you receive Medicaid?
*
Yes
No
Medicaid Number
Do you receive Extra Help(LIS)?
*
Yes
No
Not sure
Current Plan(Optional)
Back
Next
Ambetter Health Information
Ambetter Questions
Household Size
*
Estimated Annual Income
*
Do you have dependents?
*
Yes
No
Names & DOBs
Current Insurance Status
*
Please Select
Employer Coverage
Medicaid
Marketplace
None
If None, when was the last time you had coverage?
*
Do you use tobacco?
*
Yes
No
Back
Next
Life Insurance Details
Life Insurance Questions
Desired Coverage Amount
*
Please Select
10K
25K
50K
100K
Other
Beneficiary Name(s)
*
Health Conditions
*
Diabetes
High Blood Pressure
Heart Disease
None
Do you currently have life insurance?
*
Yes
No
Back
Next
Final Steps
Best Time to Contact You?
*
Please Select
Morning
Afternoon
Evening
Please check the box below to give your consent:
*
I consent to be contacted by Clark Cares Insurance Agency by phone, text, or email regarding my insurance options.
Get My Free Policy Review/Quote
Should be Empty: