Senior Insurance Agency

Client Assessment Form

Please Fill Out The Form Below: 

Do we have permission to contact you by email?

Do we have permission to contact you by phone?

1. Are you collecting Social Security income? If yes, you will be auto enrolled into Medicare A & B, 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.

3. Have you enrolled in Medicare part A & 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.

If yes, does your employer have more than 20 employees?

Do you plan to work beyond age 65?

Do you have under age 65 dependents covered on your plan?

Are you covered by a High Deductible Health Plan with contributions being made to a Health Savings Account?

Do you like the coverage and are your providers in network?

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?

For Additional Information:

If you need additional information about our client assessment form or have related questions, please don’t hesitate to contact one of our amazing agents at Senior Insurance Agency.