Client Profile for Individual & Family Rates

We understand that each person has unique healthcare needs, and by asking thorough questions, we strive to provide the best possible solutions. It is important to answer these questions to the best of your ability, as there are no wrong answers – your responses enable us to tailor our recommendations to your specific requirements.

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Referred By/Company Name

What services are you interested in?

Medical

Dental

Vision

Life

How did you hear about us?

Primary Insured

The "Primary Insured" section of our form collects important information about you as the main policyholder. Please fill out the details to the best of your ability, as it will help us determine the most suitable coverage for you.

Name

First Name

Last Name

Date of Birth

YYYY

Medical

Spouse Insured (If any)

The "Spouse Information" section of our form is optional, meaning you can skip it if you don't have a spouse or if you don't want to include them in the quotes. However, if you would like separate quotes for both you and your spouse, please provide their details in this section or mention it in the comments

Name

First Name

Last Name

Date of Birth

YYYY

Medical

Dependents

The "Dependent Information" section of our form allows you to include details about your dependents for accurate insurance quotes.

Name & Date of Births

Current Coverage

This information can usually be found on your insurance card. By gathering details about your current coverage, we can effectively compare it with the options available to ensure you have a clear understanding of all your choices.

Do you currently have coverage?

Yes

Type of Current Coverage

Current Policy Details

Please provide as much information as your current policy for a comparison

Physician Preference

If you have specific doctors that you prefer or would like us to consider when examining network options, kindly provide their information in this section.

Physician Preference

Please include all preferred doctors and hospitals

Fincial

We understand that everyone has different financial circumstances, and by considering your preferences in this area, we can tailor our recommendations to align with your financial goals and ensure you have access to the most suitable and affordable coverage options.

What is your estimated annual household income?

Desired start date for new coverage?

YYYY

Additional Information

Any other important factors that need to be considered when looking at coverage options?

Please share any other details or specific considerations that could assist us in finding the most suitable health insurance options for you.

Client Profile for Individual & Family Rates

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