Initial Questionnaire

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

* 1. Your Full Name

* 2. Email Address:

* 3. Preferred Phone:

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

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

* 6. Town / City of your primary residence

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

* 8. Date of Birth:

* 9. Do you currently receive Medicare benefits? 

* 10. Are you actively employed at this time?

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

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

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

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

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