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.

Step 1 of 2

Primary Contact (First and Last Name)*

E-Mail Address*

Phone No.*

Date of Birth*

Address*

City*

State*

Zip Code*

County*

Spouse Name

Date of Birth

Child

Gender

Male

Female

Date of Birth

Child

Gender

Male

Female

Date of Birth

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 2022 Adjusted Gross Income (AGI)? Note:(AGI can be found on the bottom of the first page (Line 8b) 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*

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.