Medicare Eligible Individuals Pre-Screen Questionnaire

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Phone:1-800-462-2322 · Fax: 214-821-6676
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As a Medicare eligible client, you have several medical plan options available to you. Help us determine which plan best fits your needs.

The state and county in which you live will impact what plans are available to you. As soon as we receive your information, we will have you a quote within 24 hours. We would love to speak with you personally, so please feel free to give us a call. Together we will determine which plan will be best for you.

Please answer the questions below:

Your Name:

Date of Birth:
Spouse's Name:

Date of Birth:

Your Physical Address:

Street Address:



Phone Number:
Alternate Number:

Are you currently covered on a Medicare supplement plan or Medicare Advantage Plan, but wish to change carriers or plan types?  Yes No

Have you enrolled in Medicare Part D?  Yes No

Do you need a Rx drug card?  Yes No

Are you a resident in a long-term care facility, such as a nursing home or assisted living?  Yes No

Are you enrolled in your State Medicade program?  Yes No

I am also interested in the following benefits or services:


 Final Expense Insurance

 Vision Insurance

 Senior Dental Plan

 Second to Die Life Insurance
(Tax Planning)

 Long Term Care Insurance

 International Travel Medical Insurance

 Maximize Asset Transfer to Children

Your Email (required):