Health Survey for Insurance Quote
Please complete all questions based on your personal healthcare needs. Information you provided doesn't guarantee you for any health coverage. Pre-existing conditions may subject to specific policy underwriting guidelines; exclusions may apply. Any information provided is not intended to be legal or tax advice.

I have opted for assistance either in person, electronically or over the phone. I am providing consent for assistance while this consent remains indefinitely unless I choose to revoke such consent in the future either in writing or verbally to my agent listed [Lin Lewis NPN# 18079192 llewis@invobh.com, 314-685-4428]

Email address *
Company
Your answer
First Name *
Your answer
Last Name *
Your answer
Address
Your answer
City & County *
Your answer
State *
Your answer
Zip *
Your answer
Phone *
Your answer
Email *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Height *
Your answer
Weight *
Your answer
Do you smoke or use e-Cigarette *
If more than 1 person need insurance, Add the person(s) name, gender & Day of Birth, height, weight, Dr, Medicine info for insurance
Your answer
Reason for shopping *
Your current insurance company name & plan info to compare; no insurance put "none"; *
Your answer
Your medicare A & B ID#; if not for Medicare put NA *
Your answer
Date to start your coverage *
MM
/
DD
/
YYYY
Your current insurance premium or max allowed $ *
Your answer
1 PERSON monthly premium $ to cover you, please be honest and realistic, e.g. a Dr. visit is ~ $200 depending on your zip code; *
Do you take any medicine? If Yes, please provide your medicine name and daily dosage for price check in next question. *
Name of prescriptions & daily dosage for price check? If None, list NA *
Your answer
How many times have you seen a doctor in the past 12 month? if more than 1, go to next Question *
If visited physician in past 12 month, please list the reasons for each of your visit and medical conditions treated? *
Your answer
Your Physician name and office ph# for network check? If no preference, list "None" *
Your answer
List any medical diagnosed conditions and surgeries in past 10 years, including the date of diagnosis, or any recommended medical procedures or surgeries have not been performed? If none, list "NA" *
Your answer
Est. 2019 Whole Household Income? *
Your answer
How many people are on your household income tax return? If more than 1, go to next question. *
Your answer
Have you or anyone else in your household on your income return lost a health coverage in the past 60 days OR is going to lose coverage in the next 60 days? Go to next Question *
Did you or anyone in your household lost a health coverage in the past 60 days OR expect to lose coverage in the next 60 days? *
If you have a Special Qualified Event above, Persons' Date of Birth on your tax return to determine your eligibility for marketplace plan (income tax to pay toward your plan)? *
Your answer
Do you need dental coverage? *
Do you need vision coverage? *
Do you need accidental medical coverage? e.g. in the event of accidents *
Do you need critical illness & cancer coverage? *
Do you need disability coverage if sick and can't go to work? *
Completing this form that I have been made aware that Short Term Medical or Hospital Indemnity Plans are not ACA plans. *
Do you have a Living Will notarized by Attorney to let your loved ones know what kind of care you want in an event that you are unable to communicate your wishes because of a debilitating injury or illness? *
Who is your Durable Power of Attorney - gives named individuals the authorities to make important healthcare, financial and end-of-life decisions on your behalf (Notarized by an Attorney) *
Do you have a Medical Directive in an event of emergency while you have clear instructions to your loved ones and medical team on how you would like your care to be? *
Do you like information to plan for your future health care cost in an event of Medical Disability and mobility, e.g. do you like your care to take place at home or a rehabilitation facility? *
Are you planned for your future healthcare, e.g. Today, it cost ~$200-$330 per Day in a rehabilitation facility to recover and gain mobility, the cost for a home aid is $20-30 per hour *
Do you have an Estate Planning in place, if you have any asset, e.g. retirement/401K, home, car, savings/investment, social security income, pension, so you can free cash to pay for your medical expense, and please list who you are working with? *
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of InvoBH - Licensed Health Insurance Advisor. Report Abuse - Terms of Service