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Medicare Quote Request

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Applicant Information

Name*
Address*
MM slash DD slash YYYY
Do you use Tobacco products?*
Do you currently work with a UNICO Medicare Advisor?
If so, please enter their name
Do you plan to retire within the next year?
What is your current health insurance?

Is your current annual Modified Adjusted Gross Income Greater or Less than $106,000?
Is your current annual Household Joint Modified Adjusted Income Greater or Less than $212,000
Annual Household Gross Income
Income Source
Expected 2025 Annual Gross Income ($)
 
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only keeping for historical data
Do you reside with a spouse or with another adult?*

Spouse/Partner Information

Spouse Name
MM slash DD slash YYYY
Does spouse use Tobacco products?*

Medicare Plan Information

Medicare Information
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Person Name
Medicare number (as shown on card)
Part A effective date
Part B effective date
 

Current Health Insurance Information

Does your company contribute any dollars to your HSA?*

Physicians and Specialists

Primary Care Physician's name
Spouse Primary Care Physician's name
Please list all specialists you are currently seeing
Please press "+" button to the right to add additional specialists
Specialty
Specialist First Name
Specialist Last Name
 
Please list all specialists your spouse currently sees
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Specialty
Specialist First Name
Specialist Last Name
 

Medications

To determine approximate costs of a prescription drug program, please list all prescription medications you take. Over-the-counter medications do not need to be listed. In the case of solutions, creams, or ointments, use size of container and refill frequency (i.e. 1 bottle every 3 months).
Please list your preferred pharmacies
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Pharmacy name
Address
 
Medication List*
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Person Name
Exact name of medication
Strength (Ex. 25mg or .05%)
Frequency (Ex. 2 per day)
 
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Confirm the Accuracy of Your Information*

I have reviewed all the information above and its accuracy to the best of my knowledge. I understand incorrect information provided may lead to increased processing time.

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Locations

1128 Lincoln Mall, Suite 200
Lincoln, NE 68508

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12120 Port Grace Blvd, Suite 102
La Vista, NE 68128

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2457 33rd Avenue
Columbus, NE 68601

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1317 W Pasewalk Ave #200
Norfolk, NE 68701

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