Individual Health Insurance Under 65 Questionnaire

Fill Out Your New Client Questionnaire Here

The information submitted here is secure and private and will not be sold or misused in any way.

"*" indicates required fields

Step 1 of 2

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Primary Contact (First and Last Name)*

E-Mail Address*

Phone No.*

Date of Birth*

MM slash DD slash YYYY

Address*

City*

State*

Zip Code*

County*

Spouse Name

Date of Birth

MM slash DD slash YYYY

Child

Gender

Male

Female

Date of Birth

MM slash DD slash YYYY

Child

Gender

Male

Female

Date of Birth

MM slash DD slash YYYY

Do you or anyone in your household currently have health insurance?*

Yes

If yes, is it individual or employer-sponsored coverage?*

When are you losing health insurance coverage?*

Please tell us the number of people in your household:*

Please tell us how many total exemptions are on your Federal 1040 tax return:*

Please tell us who needs insurance:*

What is your estimated future 2024 Adjusted Gross Income (AGI)? Note:(AGI can be found on the bottom of the first page (Line 11) of your Federal 1040 tax return):*

Instructions for finding your AGI can be found HERE

Please provide us with a brief overview of the health & wellness of yourself/family (i.e., pre-existing conditions, prescription drug coverage, exposure to claims, etc.):*

Tobacco Use*

Yes

Name of Primary Care Physician*

Physician Address*

What is your preferred contact method?*

Work Phone

Cell Phone

Other

I give Michigan Planners permission to reach out via preferred contact method.*

Yes

Prescription Drug List

Please fill out the prescription information below.

If you would like to list multiple prescriptions, please click the Plus sign next to the pharmacy box.

Prescription List*

Brand Name

Generic Name

Dosage

Quantity

Frequency

Pharmacy

Your Name*

Date of Birth*

MM slash DD slash YYYY

Phone #*

Email*

Consent*

I agree to the statement below

This is a secure form from Michigan Planners. The information submitted here is confidential and will not be compromised.

Name

This field is for validation purposes and should be left unchanged.

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First Name

Last Name

Home Phone

Zip

Date of Birth

Would you like to be contacted?

Website

Individual Insurance Under 65 New Client Questionnaire

Fill Out Your New Client Questionnaire Here

The information submitted here is secure and private and will not be sold or misused in any way.

Prescription Drug List

Please fill out the prescription information below.

If you would like to list multiple prescriptions, please click the Plus sign next to the pharmacy box.