Individual 65+ Plans Questionnaire

Today's Date: *

Contact Information:

First Name *

Last Name *

Date of birth *

Phone *

Email *

Address

Street Address *

City *

State *

Country *

Postal Code *

Does a Representative of Sandbrook Group have permission to call or email you?*

Yes

No

How do you prefer to meet:*

Medicare Info

1. Do you currently receive Social Security Benefits?

Yes

No

2. Are you currently receiving AHCCCS/ Medicaid?

Yes

No

3. If so, what is your AHCCCS ID Number?

4. Are you currently receiving Medicare?

Yes

No

5. If so, what is your Medicare ID Number? This will be required for enrollment into a plan, if you have not yet received it please indicate it in the notes below.

Yes

No

5a. Medicare ID Number (no dashes):

6. Effective Date for Part A:

6a. MM-DD-YYYY

7. Effective Date for Part B:

7a. YYYY-MM-DD

8. Gender

Female

Male

10. Primary Physician Name/ Location

11. Specialist Physicians Names/ Location

12. Preferred Pharmacy Name / Location

Current Prescriptions and Dosage

Please list current prescription medications, dosage, and frequency taken. Results are based on the accuracy of the dosage and frequency taken. Actual pricing will be an estimate and is subject to change as Carriers change their formulary and pricing.

RX #1 - Medication / Dosage / Frequency Taken

RX #2 - Medication / Dosage / Frequency Taken

RX #3 - Medication / Dosage / Frequency Taken

RX #4 - Medication / Dosage / Frequency Taken

RX #5 - Medication / Dosage / Frequency Taken

RX #6 - Medication / Dosage / Frequency Taken

RX #7 - Medication / Dosage / Frequency Taken

RX #8 - Medication / Dosage / Frequency Taken

Please list additional medications and dosages below as well as any other information that you believe we should know to place you in the best coverage.

14. Is there anything else you want us to know (or list additional medications)?

15. How did you hear about us?*

*Contact Disclaimer- By submitting your information, you acknowledge a licensed insurance agent may contact you by phone, email, or mail to discuss and quote Medicare Advantage Plans, Medicare Supplement Insurance, or Prescription Drug Plan.

**Please note that a form will be needed for each person that is applying for a policy. Spouses will need to enter in two separate forms to provide us with the most accurate information to best serve you.