We look forward to helping you find the best plan! Please complete the form below. Intake Questionnaire Medicare Pre-AssessmentCompleting this form is completely optional. Providing information give us feedback so we can learn more about what you are looking to get from your Medicare options. *The information supplied will not be shared with any 3rd party.Your Name(Required) First Last Phone Number(Required)Email Address(Required) ZIP Code(Required) How did you hear about us?(Required)Make a selection…FriendReferralExisting DoctorGoogle SearchOtherIf 'Other,' please tell us how you found us Your Current CoverageI am looking for coverage for:(Required)Make a selection…MyselfMyself and spouseSpouse onlyDo you currently have health insurance?(Required)Make a selection…YesNoMy Current Coverage(Required)Make a selection…Still working – on employer coverage (self or spouse)Retired – retiree plan (i.e. union or state)COBRAPurchased my own or individual coverageIf you are still working, is your employer larger than 20 employees?Make a selection…YesNoN/AHave you started Social Security Retirement?(Required)Make a selection…YesNoMarital Status(Required)Make a selection…MarriedSingleSingle with roommateYour ProfileHow Familiar are you with your Medicare options?(Required) I know exactly what I want I have some questions Unsure & just starting the process Do you know the differences between Medicare Advantage and Medicare Supplement?(Required) Yes No Somewhat Would you prefer a plan with a low to zero monthly premium and a maximum out of pocket or to pay a premium (i.e. $125 – $200/month) and have low out of pocket medical expenses?(Required) 1 – lowest possible monthly premium 2 3 4 5 – lowest out-of-pocket medical Do you have a primary care physician?(Required)Make a selection…YesNoAre you more comfortable with having a insurance network that is local HMO and possibly lower co-pays vs National – PPO and higher out of pocket/co-pays(Required) 1 – it’s fine with me 2 3 4 5 – deal breaker Your comments or questionsPlease type the missing letter: A __ C D(Required) Consent(Required) I agree to the privacy policy.You can view the privacy policy here.PhoneThis field is for validation purposes and should be left unchanged.
