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Phone 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? *
Have 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 info@medicare-planning.com
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 month
