Routt Insurance (Life · Health · Medicare · Dental

Routt Insurance (Life · Health · Medicare · Dental · Vision)

Robert B. Routt, State Licensed Insurance Agent, 3455 Countryside Blvd, Clearwater, FL 33761, (727) 513-8338, NPN 546852. Completing this form helps us understand your insurance needs; it does not bind coverage. We handle your information with privacy in mind. (Secure Form)
Primary Applicant
Legal Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
SSN Last 4
Marital Status
Address
Street Address
Apartment / Unit
City
State
ZIP Code
County
Residency Status
Mailing Address if Different
Contact
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Methods
Household Members
Spouse/Partner Full Name

First NameMiddle NameLast Name
Spouse/Partner Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse/Partner Gender
Relationship to Primary Applicant
Dependents
Dependent Details
Additional Household Information
Products and Coverage Interests
Products of Interest
Reason for Inquiry
Desired Timeline
How did you hear about us?

Other
Do you currently have coverage?
Current Carrier
Current Plan Type
Current Monthly Premium
Current Coverage Effective/Renewal Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What works / what does not work with your current coverage?
Medicare Details
Part A effective date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Part B effective date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you have Part D coverage?
Which Medicare coverage are you most interested in?

Other
Programs or assistance you may have

Other
Current prescriptions
Primary doctors and pharmacies
Do you currently use tobacco?
Health and Life Underwriting
Have you used tobacco or nicotine in the last 12 months?
Height (inches)
Weight (lbs)

Additional medical details
Life-Specific Details
Primary purpose for life coverage

Other
Desired coverage amount band
Existing life insurance policies

Other
Beneficiary information
Florida replacement notice acknowledgment
Dental and Vision
Dental needs

Other
Vision needs

Other

Goals and Notes
Primary goal
Additional notes
Consents and Signature
Permission to contact me by phone, text, or email
Medicare scope-of-appointment acknowledgment
Permission to share my information with carriers
MIB and underwriting acknowledgment
Accuracy attestation
Coverage acknowledgment
E-signature name

First NameMiddle NameLast Name
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Next Steps
Preferred quote delivery method
Preferred appointment windows
Should be Empty:

Rows	Yes	No
Heart disease
Cancer
Diabetes
COPD or other lung disease
Stroke or TIA
Kidney disease
Mental health condition
HIV or AIDS
Alcohol or drug use treatment
Pending surgery
Disability
Hospitalized in the last 5 years
Other major condition

Rows	Current dental plan	Current vision plan	Last exam date	Waiting period concern
Dental
Vision

Routt Insurance (Life · Health · Medicare · Dental · Vision)

Primary Applicant

Address

Contact

Household Members

Products and Coverage Interests

Medicare Details

Health and Life Underwriting

Life-Specific Details

Dental and Vision

Goals and Notes

Consents and Signature

Next Steps