Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone Number: *Date Of Birth: *Family Nearby: *Full Address: *Email: *Medicare ID/Number: *Which Parts of Medicare do you currently have (Part A and/or Part B)? *If you do have Part A, what date did you get it? *If you do have Part B, what date did you get it? *Do you currently have a Medicare Supplement Plan OR Medicare Advantage Plan? *If so, what Supplement Plan do you have or what Medicare Advantage Plan Do you currently have? *If so, what is your current monthly premium? *If so, why did you pick that particular Medicare Supplement OR Medicare Advantage Plan? *Do you have a history of Cancer, Heart attack or Stroke in your family? *Have you had a family member use home health care or go into a nursing home? *If so, how did they pay for it? *How would you pay for it? *Do you currently carry Life Insurance? *What is the Death Benefit? *What is your premium? *What is the Cash value? *If you have life insurance, what purpose does it serve for you and your family? *If you have life insurance, what purpose does it serve for you and your family?Income replacementFinal expensesOutstanding debtsHelp family financiallyHave you made any arrangements to take care of final expenses? *Are you satisfied with the present rate of return on your investments? *Are you dealing with the stock market OR the bank? *Do you have a 401k / 403B / 457? If YES, what did you roll it into? *Would you like to have us quote insurance for your Home , Auto , Boat, etc to see if we can save your some premium dollars in addition to insuring you have proper coverage? *If YES, please provide your most current Declaration pages for your Home, Auto, Boat, etc. AND Driver’s license Number by Email or FAX or regular mail *Would you also like quotes for Dental / Vision and Hearing Insurance? *. Who else (family, friends...etc) do you think could benefit from learning about their options for Medicare (i.e Medicare Supplement, Medicare Advantage, Part D Prescription Drug)? *Do you currently have a Long-Term Care (LTC) Policy in place? *If YES, would you like it reviewed? *If NO, would you like for us to quote options for you? *Pharmacy Preference’s *Current Drug Plan: *List your current prescriptions. Please include drug name, dosage in milligrams (MG) tablet or capsules and quantity that you take per monthSubmit
