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 currently work with a UNICO Medicare Advisor?

Karla Wilson
Nikki Bruns
Jennifer Farnsworth
No

Were you referred by someone?

If so, please enter their name

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)

Tax Filing Status

Is your current annual Modified Adjusted Gross Income Greater or Less than $97,000?

Greater
Less

Is your current annual Household Joint Modified Adjusted Income Greater or Less than $194,000?

Greater
Less

Annual Household Income

Income Source	Expected 2024 Annual Income ($)

Hidden

If greater, what was the approximate amount?-dnu

only keeping for historical data

Do you reside with a spouse or with another adult?*

Yes
No

Spouse/Partner Information

Spouse Name

First Last

Spouse Date of Birth

Does spouse use Tobacco products?*

Yes
No

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.

Do you or your spouse take prescription medications?*

Medication List*

Person Name	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?