<\/p>

<\/ul><\/div>\n
\n

\n<\/fieldset>\n

Your Full Name
\n<\/span> <\/label>\n<\/p>\n

Phone Number
\n<\/span> <\/label>\n<\/p>\n

Date Of Birth
\n<\/span> <\/label>\n<\/p>\n

Family Nearby
\n<\/span> <\/label>\n<\/p>\n

Your Full Address
\n<\/span> <\/label>\n<\/p>\n

Email
\n<\/span> <\/label>\n<\/p>\n

Medicare ID Number
\n<\/span>
\n<\/label>\n<\/p>\n

Which Parts of Medicare do you currently have (Part A and\/or Part B)?
\n<\/span>
\n<\/label>\n<\/p>\n

If you do have Part A, what date did you get it?
\n<\/span>
\n<\/label>\n<\/p>\n

If you do have Part B, what date did you get it?
\n<\/span>
\n<\/label>\n<\/p>\n

Do you currently have a Medicare Supplement Plan OR Medicare Advantage Plan?
\n<\/span>
\n<\/label>\n<\/p>\n

If so, what Supplement Plan do you have or what Medicare Advantage Plan Do you
\ncurrently have?
\n<\/span>
\n<\/label>\n<\/p>\n

If so, what is your current monthly premium?
\n<\/span>
\n<\/label>\n<\/p>\n

If so, why did you pick that particular Medicare Supplement OR Medicare Advantage
\nPlan?
\n<\/span>
\n<\/label>\n<\/p>\n

Do you have a history of Cancer, Heart attack or Stroke in your family?
\n<\/span>
\n<\/label>\n<\/p>\n

Have you had a family member use home health care or go into a nursing home?
\n<\/span>
\n<\/label>\n<\/p>\n

If so, how did they pay for it?
\n<\/span>
\n<\/label>\n<\/p>\n

How would you pay for it?
\n<\/span>
\n<\/label>\n<\/p>\n

Do you currently carry Life Insurance?
\n<\/span>
\n<\/label>\n<\/p>\n

What is the Death Benefit?
\n<\/span>
\n<\/label>\n<\/p>\n

What is your premium?
\n<\/span>
\n<\/label>\n<\/p>\n

What is the Cash value?
\n<\/span>
\n<\/label>\n<\/p>\n

If you have life insurance, what purpose does it serve for you and your family?
\n<\/span>
\n<\/label>\n<\/p>\n

Have you made any arrangements to take care of final expenses?
\n<\/span>
\n<\/label>\n<\/p>\n

Are you satisfied with the present rate of return on your investments?
\n<\/span>
\n<\/label>\n<\/p>\n

Are you dealing with the stock market OR the bank?
\n<\/span>
\n<\/label>\n<\/p>\n

Do you have a 401k \/ 403B \/ 457?
\n<\/span>
\n<\/label>\n<\/p>\n

If YES, what did you roll it into?
\n<\/span>
\n<\/label>\n<\/p>\n

Would you like to have us quote insurance for your Home , Auto , Boat, etc to see if we can save
\nyour some premium dollars in addition to insuring you have proper coverage?
\n<\/span>
\n<\/label>\n<\/p>\n

If YES, please provide your most current Declaration pages for your Home, Auto, Boat,
\netc. AND Driver\u2019s license Number by Email or FAX or regular mail
\n<\/span>
\n<\/label>\n<\/p>\n

Would you also like quotes for Dental \/ Vision and Hearing Insurance?
\n<\/span>
\n<\/label>\n<\/p>\n

Who else (family, friends...etc) do you think could benefit from learning about their options for
\nMedicare (i.e Medicare Supplement, Medicare Advantage, Part D Prescription Drug) ?
\n<\/span>
\n<\/label>\n<\/p>\n

Do you currently have a Long-Term Care (LTC) Policy in place?
\n<\/span>
\n<\/label>\n<\/p>\n

If YES, would you like it reviewed?
\n<\/span>
\n<\/label>\n<\/p>\n

If NO, would you like for us to quote options for you?
\n<\/span>
\n<\/label>\n<\/p>\n

Medication List
\n Pharmacy Preference\u2019s
\n<\/span>
\n<\/label>\n<\/p>\n

Current Drug Plan if you have one.
\n<\/span>
\n<\/label>\n<\/p>\n

List your current prescriptions. Please include drug name, dosage in
\nmilligrams (MG) tablet or capsules and quantity that you take per month
\n<\/span>
\n<\/label>\n<\/p>\n

If you have a PDF or word document of your prescriptions, you can upload it here
\n<\/span>
\n<\/label>\n<\/p>\n

Click to Submit!
\n
\n<\/label>\n<\/p>

<\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"

Filling out the Medicare Client Needs Assessment form is crucial […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"_uf_show_specific_survey":0,"_uf_disable_surveys":false,"_price":"","_stock":"","_tribe_ticket_header":"","_tribe_default_ticket_provider":"","_tribe_ticket_capacity":"0","_ticket_start_date":"","_ticket_end_date":"","_tribe_ticket_show_description":"","_tribe_ticket_show_not_going":false,"_tribe_ticket_use_global_stock":"","_tribe_ticket_global_stock_level":"","_global_stock_mode":"","_global_stock_cap":"","_tribe_rsvp_for_event":"","_tribe_ticket_going_count":"","_tribe_ticket_not_going_count":"","_tribe_tickets_list":"[]","_tribe_ticket_has_attendee_info_fields":false,"footnotes":""},"class_list":["post-3393","page","type-page","status-publish","hentry"],"yoast_head":"\n