Client Intake Form

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Client Intake Form

Client information for Liz Rosenbaum, individual and Family health insurance broker for plans on Colorado Connect for Health
Contact info:
email: LizRosenbaumC4H@gmail.com
Cell: 719-661-5108
Office: 719-382-0406

Email *

Please leave your name here:

What is the best phone number for you? *

Are you already my client? I still need you to complete this form, thank you so much! *

Yes

Not yet

How many people in your household need health insurance? *

Just me

spouse / significant other

Child(ren) up to age 18

college student(s) up to age 26

Required

Which option/s describes your income *

full time employee

part time employee

Gig economy, delivery etc

Self employed / sole proprieter

retired

none of these

Required

When was the last time you had health insurance? *

What was the type / name of insurance you last had? Or the name of your current insurance. *

What do you need from your health insurance? click all that apply *

Co-pays , you pay a small amount per doctor visit

low deductible, you think you have an upcoming surgery

higher deductible, you are healthy and need lower monthly payments

you have gone to the emergency room at least once last year

you rarely go to the doctor

you need to do several doctor appointments throughout the year

You have something specific you need coverage for, we will only discuss this on the phone for privacy reasons (HIPAA)

you need monthly prescriptions included in your decision for a plan

other:

Required

Additional Notes

Personal information will / can be discussed over the phone for your privacy. This is a basic form to begin the process to acquire health insurance. Sometimes this process is fast, other times it requires a lot of patience, and we are operating on deadlines for payments and registrations.
Disclaimer: I do not have access to all insurance companies, if I cannot assist you I will do my best to offer a referral. My goal is to work with you, educate you about health insurance, and provide a way for you to feel empowered about your choices regarding your health and ultimately find a health insurance plan that works for your lifestyle and budget.

A copy of your responses will be emailed to the address you provided.

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