Initial Questionnaire

Thank you for taking the time to complete our Initial Questionnaire to better address your needs.

Your Full Name

Question Title

* 1. Your Full Name

Email Address:

Question Title

* 2. Email Address:

Preferred Phone:

Question Title

* 3. Preferred Phone:

What is your preferred and most convenient method for communications?

Question Title

* 4. What is your preferred and most convenient method for communications?

Is there a time of day that is best to reach you?

Question Title

* 5. Is there a time of day that is best to reach you?

Town / City of your primary residence

Question Title

* 6. Town / City of your primary residence

In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

Question Title

* 7. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

Date of Birth:

Question Title

* 8. Date of Birth:

Do you currently receive Medicare benefits? 

Question Title

* 9. Do you currently receive Medicare benefits? 

Are you actively employed at this time?

Question Title

* 10. Are you actively employed at this time?

How many employees currently work at the location where you work?

Question Title

* 12. How many employees currently work at the location where you work?

Is there an expected end date to your current Employer Group Health Plan coverage? If so, please provide additional information

Question Title

* 13. Is there an expected end date to your current Employer Group Health Plan coverage? If so, please provide additional information

Do you currently contribute to a Health Savings Account (HSA)?

Question Title

* 14. Do you currently contribute to a Health Savings Account (HSA)?

Medicare Premiums are, in part, income-related. Based on your last Tax Returns, what is your Modified Adjusted Gross Income?

Question Title

* 15. Medicare Premiums are, in part, income-related. Based on your last Tax Returns, what is your Modified Adjusted Gross Income?

Please provide any additional information you would like as it relates to your Medicare and retirement health insurance options.

Question Title

* 16. Please provide any additional information you would like as it relates to your Medicare and retirement health insurance options.

T