Medicare Client Needs Assessment

Your Full Name

Phone Number

Date Of Birth

Family Nearby

Your Full Address

Email

Medicare ID Number

Which Parts of Medicare do you currently have (Part A and/or Part B)?

If you do have Part A, what date did you get it?

If you do have Part B, what date did you get it?

Do you currently have a Medicare Supplement Plan OR Medicare Advantage Plan?

If so, what Supplement Plan do you have or what Medicare Advantage Plan Do you
currently have?

If so, what is your current monthly premium?

If so, why did you pick that particular Medicare Supplement OR Medicare Advantage
Plan?

Do you have a history of Cancer, Heart attack or Stroke in your family?

Have you had a family member use home health care or go into a nursing home?

If so, how did they pay for it?

How would you pay for it?

Do you currently carry Life Insurance?

What is the Death Benefit?

What is your premium?

What is the Cash value?

If you have life insurance, what purpose does it serve for you and your family?

Have you made any arrangements to take care of final expenses?

Are you satisfied with the present rate of return on your investments?

Are you dealing with the stock market OR the bank?

Do you have a 401k / 403B / 457?

If YES, what did you roll it into?

Would you like to have us quote insurance for your Home , Auto , Boat, etc to see if we can save
your some premium dollars in addition to insuring you have proper coverage?

If YES, please provide your most current Declaration pages for your Home, Auto, Boat,
etc. AND Driver’s license Number by Email or FAX or regular mail

Would you also like quotes for Dental / Vision and Hearing Insurance?

Who else (family, friends...etc) do you think could benefit from learning about their options for
Medicare (i.e Medicare Supplement, Medicare Advantage, Part D Prescription Drug) ?

Do you currently have a Long-Term Care (LTC) Policy in place?

If YES, would you like it reviewed?

If NO, would you like for us to quote options for you?

Medication List
Pharmacy Preference’s

Current Drug Plan if you have one.

List your current prescriptions. Please include drug name, dosage in
milligrams (MG) tablet or capsules and quantity that you take per month

If you have a PDF or word document of your prescriptions, you can upload it here

Click to Submit!