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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.
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Primary Contact (First and Last Name)
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E-Mail Address
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Date of Birth
*
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Address
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State
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Zip Code
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Spouse Name
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MM slash DD slash YYYY
Child
Gender
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Date of Birth
MM slash DD slash YYYY
Child
Gender
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Female
Date of Birth
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Do you or anyone in your household currently have health insurance?
*
Yes
No
If yes, is it individual or employer-sponsored coverage?
*
When are you losing health insurance coverage?
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Please tell us the number of people in your household:
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Please tell us how many total exemptions are on your Federal 1040 tax return:
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Please tell us who needs insurance:
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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
No
Name of Primary Care Physician
*
Physician Address
*
What is your preferred contact method?
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Work Phone
Cell Phone
Email
Other
I give Michigan Planners permission to reach out via preferred contact method.
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Yes
No
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
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Brand Name
Generic Name
Dosage
Quantity
Frequency
Pharmacy
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Your Name
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Date of Birth
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Phone #
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Consent
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