Healthcare Survey Charlotte's Healthcare Advisory Group, LLC General Information Questionnaire Question Title * 1. Please indicate what type of insurance you are looking for today? Select all that apply. Traditional Medical Healthcare Insurance Medicare Advantage Plan (Includes Part D Prescription Drug Plan)Must have Medicare Pa rt A and Part B to qualify. Dental Insurance Life Insurance Vision Insurance Medicare Supplement Plan Prescription Drug Plan Question Title * 2. What is your first and last name? Question Title * 3. What is your gender? Female Male Other (specify) Question Title * 4. When is your birthday? Month/Day/Year Date Question Title * 5. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”. Question Title * 6. What is your current weight in pounds? Question Title * 7. Do you currently smoke cigarettes, or not? Yes, I do No, I do not I have never smoked Question Title * 8. Why do you currently not have health insurance? (Check all that apply) Insurance company refused coverage for health reasons I am in between jobs. Employer does not pay for insurance Not eligible for employer-paid insurance Dissatisfied with previous insurance plan or provider Cannot afford insurance I have insurance, I am just looking for better benefits. Other (please specify) Question Title * 9. Enter your active EMAIL ADDRESS AND TELEPHONE NUMBER HERE to receive your FREE QUOTES Question Title * 10. Enter Your Residential Mailing Address SUBMIT