Intake Form

Preliminary Insured Information Submission Form. This is not issuance of health insurance. You must review a formal application with a LIVE Health Insurance Agent to determine your needs and eligibility. NOTE: No Fees will ever be collected, unless by a licensed agent upon you authorizing a contract for health insurance services.

Primary Applicant Info:

Company

Address

Street Address

City

State

Country

Postal Code

Date of Birth *

Gross Annual Household Income *

List all prescribed medication taken, how often, for what reason, include current medical condition if applicable. If none, type NONE/NA.

What Type of Plan are You Looking For? *

Under 65 Insurance

Medicare/Medigap

Other

Spouse Info:

Do you wish to apply a spouse for coverage? *

No

Yes

Spouse Occupation *

List all spouse's prescribed medication taken, how often, for what reason, include current medical condition or medical history: including heart, stroke, cancer, injuries, ongoing treatments or treatment recommendations pending. *

Dependent(s) Info:

How Many Dependents Need Coverage? *

Dependent 1:

Dependent 1 Full Name *

Dependent 1 Tobacco? *

No

Yes

Dependent 2:

Dependent 3:

Dependent 4:

Dependent 5:

Please list any dependents with any medical conditions and/or prescribed medication(s). List all prescribed medication taken, how often, for what reason, include current medical condition or medical history: including heart, stroke, cancer, injuries, ongoing treatments or treatment recommendations pending.

General Health Questions

Are currently insured by a major medical plan, shared health plan, or Obamacare? *

Yes

No

Not Sure

Are currently insured by your employer plan? *

Yes

No

Not Sure

What is the name of your current plan? *

Current Premium, Deductible and Out of Pocket Max? *

Premium/Deductible/Out of Pocket Max

List any doctors you MUST be able to continue to see (if applicable): *

Anything else you want us to know regarding your situation?

Do you need to protect your family with any of the following? *

Dental Insurance

Vision Insurance

Accident Insurance

Life Insurance (enough to....replace your income for 10 years, pay off all debts, college fund, funeral expenses) **

None of the Above

** Note: even if you have life insurance through your employer, you will likely lose it if you leave that employer. It is important to have separate life insurance that stays with you through any employment transitions

Preferred Eye Doctor

How ready are you in making a health care insurance decision? *

It is urgent that I get coverage and am ready to move forward.

I would like to schedule an appointment to answer my questions.

Within 6 Months

Within 12 Months

Greater than 1 Year

Be sure to schedule an appointment on our calendar after submission of this form.

Terms and Conditions

Please Click to Agree

Information entered is confidential for the exclusive use of The Pierce Insurance Group and will not be shared with outside 3rd parties. I agree to receive contact via phone call, email, and/or text messages regarding my health plan options.

Privacy Policy

Kimberly Pierce

Phone: (715) 999-6715

Email: [email protected]

NPN: 21324757

Dependent 1:

Dependent 2:

Dependent 3:

Dependent 4:

Dependent 5: