Medicare Quote Request

Applicant Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Do you use Tobacco products?*

Yes
No

Contact phone number*

Contact Email

Do you plan to retire within the next year?

Yes
No

What is your current health insurance?

Employer Sponsored Group Plan
Individual Health Insurance (e.g. Healthcare.gov)

Is your current annual Modified Adjusted Gross Income Greater or Less than $85,000?

Greater
Less

Is your current annual Modified Adjusted Income Greater or Less than $170,000?

Greater
Less

If greater, what was the approximate amount?

Do you reside with a spouse or with another adult?

Yes
No

Spouse Name

First Last

Spouse Date of Birth

Current Health Insurance Information

What is the premium for your current health plan?

What is the deductible for your current company health plan?

What is the maximum out of pocket expense you could incur?

Is this an HSA eligible plan?

Does your company contribute any dollars to your HSA?

Yes
No

Medications

To determine approximate costs of a prescription drug program, please list all prescription medications you take. In the case of solutions, creams, or ointments, use size of container and refill frequency.

Medication List

Exact name of medication	Strength (Ex. 25mg or .05%)	Frequency (Ex. 2 per day)

Please press "+" button to the right to add additional medications

Which pharmacy do you use?

Medicare Quote Request

Applicant Information

Current Health Insurance Information

Medications

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