Medicare Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
Your Date of Birth
*
-
Month
-
Day
Year
Date
Your Home Zip Code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you on OR do you anticipate taking any medications over the next 12 months?
*
Yes
No
List All Current Medications (Drug Name, MG Amount, and Pills received each month)
*
Example: Lipitor 40mg, 30pills, Metoprolol 25mg 60 pills, etc. Please have CORRECT spelling of drug name to ensure accuracy.
Does your spouse have a Medicare supplement policy? **Carriers offer household discounts when spouses choose the same carrier, so we need to know if a discount is applicable**
*
Yes
No
What carrier is your spouse using?
Example: AARP/UHC, Cigna, etc.
Are you currently enrolled in a Medicare Part D Drug?
*
Yes
No
Please list your Part D Drug plan name and monthly premium
*
What Pharmacy do you use? Example: CVS in Cranford, NJ
Check any pharmacies shown below that you would be willing to use
CVS
Walgreens
Walmart
Costco
NONE - Only use my pharmacy
Check any items below which you would want more information on as we run the Medicare Analysis **items below are not covered by traditional Medicare & would be a separate policy if desired**
Long Term Care Insurance
Dental Insurance
Cancer Insurance
Life Insurance
Other
Requested Effective Date
-
Month
-
Day
Year
Date
Any additional comments/notes we should be made aware of:
Submit
Should be Empty: