Initial Questionnaire

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

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* 1. Your Full Name

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* 2. Email Address:

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* 3. Preferred Phone:

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

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

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* 6. Town / City of your primary residence

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

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* 8. Date of Birth:

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* 9. Do you currently receive Medicare benefits? 

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* 10. Are you actively employed at this time?

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* 11. Do you currently have health insurance coverage through your Employer Sponsored Group Health Plan?

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

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

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

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

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

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