New Client Health Questionnaire

Please take a few minutes to fill out this intake form. This will allow me to get your best options ready to go over together at our appointment time. This connection is encrypted (see the lock symbol in the top left of the URL), so your information is secure.

Name & Date of Birth or age (DOB preferred) for Each Person You Want to Include on Your Policy *

Estimated Yearly Household Income (For those that are self employed, subtract business expenses from this number). *

How do you file your taxes? (Joint or Single) *

Joint

Single

How many dependents do you claim? *

Tobacco Status (If answering No, then all members of the policy do not use tobacco.) *

Yes

Prescriptions Being Taken and Reason for Use for Each Person Included on the Policy *

Approximate Height & Weight for Any Adult on the Policy *

Any health conditions for each person on the policy? If so, what treatment is recommended and/or needed? If nothing, please respond "N/A". *

When we find you the right solution, what is your tentative start date? (Immediately tomorrow/ Next week/ Next month, etc.) *

What is your specific budget range/what are you currently paying or what will your COBRA be? (If you're currently on an employer plan, the employer is paying 50% or more of your employee-only option monthly premiums.) *

Any must-have Doctors, Pediatricians, Specialists, Dentist, Optometrist, etc.? Our goal is to make sure they are in-network with whichever carrier you choose. If yes, please list their FULL NAME, what type of doctor, and city or zip-code they practice in. If none, please respond "N/A". (For Example Dr. Macy Smith, OBGYN, Hendersonville, TN 37075) *

Do you go to the doctor more than 5x/year so you want to pay a little more on a monthly basis to have lower copays when you see the doctor/specialist? Or, do you never go and just want to make sure you're financially protected in the case of a catastrophic accident/ injury/ hospitalization/ critical illness, etc.? *

Do you need Maternity Coverage? *

Yes

Do you need Yearly Routine Wellness Exams covered in full? *

Yes

Do you need Mental Health coverage? *

Yes

Would you like Dental and Vision Insurance? *

Yes

Were you referred by someone? If so, please provide their name. *

What is a good day/time that I can answer your questions so that you can simply then pick the carrier/plan that best fits your needs? *

What is your reason for seeking coverage at this time? *

Is there any specific need/service you are wanting from your plan? (e.g. physical therapy, medication need, or just coverage in case of a costly major medical event) *