Your Coverage Profile
A few details so we can match you with the best coverage.
Your Privacy Matters at Beach Benefits Group
The information you provide is encrypted and kept secure. Only the licensed owners of Beach Benefits Group can access it. Your information is never sold or shared and will only be used to help find the right coverage for you. If you would prefer to talk or text, please contact: Debbie at 239-571-0620 or Scott at 941-704-5340. Or email: debbie@thebeachbenefitsgroup.com or scott@thebeachbenefitsgroup.com
Full Legal Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Zip Code
*
Name of the county in Florida where you reside?
*
Have you have used any tobacco/nicotine products in the last 6-36 months?
*
Never
Within the last 6 monthis
Within the last 12 months
Over 12 months ago
Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
May we text you?
*
Yes
No
What is your preferred method of communication?
*
Phone Call
Text
Email
Zoom
In Person
Are there any day(s) and time(s) that work best for you and a phone call?
Is there anyone else to be covered? Spouse/partner and/or children? If so, please list their names, date of birth, zip code if different than yours. Tobacco use.
Are you losing/lost health insurance coverage? If so, when does/did it end?
Do you travel out of the country and want coverage out of the US?
Do you travel out of the state and want coverage, other than for emergencies, out of Florida?
Do you have a Primary Care Physician or Specialist that you require to be in network? If so, list their name(s) and practice. Or, are you open to changing providers if there is a plan that is more affordable?
This applies only to health insurance, not Medicare Advantage. Do you want to find out if you qualify for a Premium Tax Credit that can assist with lowering the cost of your insurance premiums? If you're unsure of how this works, let's talk further.
What kind of coverage(s) are you interested in?
*
Health Insurance
Medicare Advantage or Med Sup
Medicare DSNP - dual eligible for Medicare and Medicaid
Short Term Disability
Life Insurance
Dental
Vision
Accident Indemnity
Critical Illness with Cancer
Hospital Indemnity
Travel Insurance for Coverage outside of the US
Cigna Global for year-round coverage for non-US or dual citizens
For Medicare Advantage or Medicare Supplements only: Are you currently enrolled or registered for:
Medicare Parts A and B
Medicaid
Unsure and would like to learn more
Do you have any additional Information and/or questions?
Name of the person that referred you?
Submit
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