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Medicare
Retirement
Social Security
Contact Us
- About Us
- Schedule Your Medicare Review
Resources
- Blog
- Video

First Name *

Last Name *

Phone *

Email *

Date of birth *

Address *

Street Address

City

State

Country

Postal code

Preferred Contact Method

Preferred Method *

Phone

Email

SMS / Text

What would you like to accomplish in today's conversation? *

Help Needed

Which Services Are You Interested In? *

Medicare Coverage

Do You Currently Have Medicare *

Yes

No

Current Medicare Plan Type?

Part A

Part B

Part C (Advantage)

Part D (Prescription)

Supplement Plan

Do you have any preferred doctors or specialists? *

Yes

No

If yes, list providers:

Do you take any prescription medications regularly? *

Yes

No

If yes, list medications

Do you have any concerns about coverage costs? *

Yes

No

If yes, explain the concerns:

Are you receiving any of the following? *

Medicaid

Extra Help

VA/TRICARE

None

Would you like a review of additional benefits (vision, dental, OTC perks, etc.)? *

Yes

No

Share your health history *

Do you or your family have any history of a any of the following? *

Do you or your family have any history of any of the following? *

Estate Planning

Do you currently have any estate planning documents? *

Will

Trust

Power of Attorney

Healthcare Directive

Do you have designated beneficiaries for assets? *

Yes

No

If yes, list down primary beneficiaries:

Do you have living trust? *

Yes

No

Unsure

Do you have concerns about estate taxes or wealth transfer? *

Yes

No

If yes, explain:

Do you have a power of attorney for finances and healthcare?

Yes

No

Main goals for your estate plan: *

Avoid probate

Protect assets

Ensure medical wishes

Leave a legacy/gift

Unsure—need guidance

Life Insurance

Do you currently have a life insurance? *

Yes

No

If yes, what type?

Term

Whole Life

Universal

Final Expense

Desired coverage amount: *

Do you have beneficiaries designated? *

Yes

No

If yes, list primary beneficiaries:

Goal for new or existing policy: *

Cover funeral costs

Leave an inheritance

Protect spouse/family income

Replace old coverage

Annuities and Retirement Income

Are you currently receiving income from an annuity? *

Yes

No

Type of annuity interest: *

Fixed

Indexed

Hybrid

Expected retirement age: *

Retirement income sources: *

Social Security

Pension

401(k)/IRA

Other:

Main concern(s): *

Running out of money

Protecting from market losses

Creating guaranteed monthly income

Avoiding tax penalties

Is there anything else we should know? *

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