Client Information WorkSheet

Please complete the following information as best as you can
and one of our agents will be in touch to review your Medicare options.

Client One


Client Two

Retired: YesNo

If you or your spouse is currently on an employer plan...

What is your current premium?

Are you obligated to continue your employer plan in order to keep a pension or any other retiree benefit?

Does your employer provide retiree health benefits?

If Yes, what is the monthly premium for your retiree health benefits?

Medical Expenses

Client One

Client Two

Do you currently have a Medicare Advantage or Medicare Supplement Plan? YesNo
If YES, who is the carrier?

Would you prefer to have $0 monthly premium but have higher deductibles, or pay a monthly premium and have little to no deductibles? $0 PremiumPay Premium, little to no deductible
Do you have any planned procedures coming up or expect to need any major procedures in the next year?

The greatest compliment we can receive is a referral of your family or friends!