Full Name

Date of Birth

Email Address

Zip Code

Phone Number

Do we have permission to contact you by email? Do we have permission to contact you by email? Yes No

Do we have permission to contact you by phone? Do we have permission to contact you by phone? Yes No

1. Are you collecting Social Security income? If yes, you will be auto enrolled into Medicare A & B, skip to #4. 1. Are you collecting Social Security income? If yes, you will be auto enrolled into Medicare A & B, skip to #4. Yes No

2. As of today are you within 3 months of your 65th birth month? If no, you must wait to apply. We will email instructions then, skip to #4. 2. As of today are you within 3 months of your 65th birth month? If no, you must wait to apply. We will email instructions then, skip to #4. Yes No

3. Have you enrolled in Medicare part A & B? 3. Have you enrolled in Medicare part A & B? A B A & B Neither A nor B

4. Are you covered by an employer group plan you can keep beyond age 65? If no, I’ll send an email explaining how to enroll in Medicare A & B. Skip to #5. 4. Are you covered by an employer group plan you can keep beyond age 65? If no, I’ll send an email explaining how to enroll in Medicare A & B. Skip to #5. Yes No

If yes, does your employer have more than 20 employees? If yes, does your employer have more than 20 employees? Yes No

Do you plan to work beyond age 65? Do you plan to work beyond age 65? Yes No

How much do you pay for your group health coverage?

Do you have under age 65 dependents covered on your plan? Do you have under age 65 dependents covered on your plan? Yes No

What is the deductible? ($)

What is the maximum annual out of pocket limit? ($)

Are you covered by a High Deductible Health Plan with contributions being made to a Health Savings Account? Are you covered by a High Deductible Health Plan with contributions being made to a Health Savings Account? Yes No

Do you like the coverage and are your providers in network? Do you like the coverage and are your providers in network? Yes No

5. In the last few years has your annual Modified Adjusted Gross Income exceeded, or this year will it exceed $97,000.00 Single/$194,000.00 Joint? 5. In the last few years has your annual Modified Adjusted Gross Income exceeded, or this year will it exceed $97,000.00 Single/$194,000.00 Joint? Yes No