New Client Discovery Form

Customer Intake Form

Primary Applicant Information...

First Name

Last Name

Phone:

Gender:

🚹 MALE
🚺 FEMALE
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Date of Birth:

🏠 Household Size*

1
2
3
4
5
6
7
8
9
10+
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Email:

Marital Status*

Single
Married
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Employment Status

Employed (W2)
Self-Employed (1099)
Unemployed
Disability
Retired
Other
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Annual Income:

Citizenship Status:

US Citizen
Permanent Resident
Temporary Resident
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Employer Name

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Lead Type:

Aged
Agent Website
Banner
Contact Me Form
Facebook
Former Client
Inbound Call
Inbound Call - Transfer
Medicare Age-In
Outbound Call
Walk & Talk
Website
Referral
Community Event
Dakota HS Sponsorship
Circle of Influence
Network
Online Lead | 3rd Party
Live Transfer | 3rd Party
Live Transfer | H.M.
PDL
WALK-IN
OTHER
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Client Type

🔴 Medicare
🔵 Healthcare
⚪️ Other
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Client Status

Not Contacted
Working Lead
Callback Requested
Customer Will Call Back
Quoted
Pending
Active
No Sale
No Sale - No Answer
No Sale - Medicaid
No Sale - Insurance Not Desired
No Sale - Covered by Competitor
Inactive
Declined
Withdrawn
Cancelled
Terminated
Passed Away
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Street Address

City

State

Postal Code

County

What exactly are you looking for?

What are we looking to solve today?

DISCOVER THE "PURPOSE" OF THE MEETING

Product Types:

ACA Health Plan
Medicare Advantage
Medicare Supplement
Part D (PDP)
STM
TriTerm
Hospital Indemnity
Supplemental
Life Insurance
MAPD
MA ONLY
MEDIGAP
PDP
ACA
ACA-OFF EXCHANGE
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Let's discuss your current plan...

Are you covered currently?

Yes

No

Current Plan Satisfaction

BadGood

Current Plan Cost:

$

TOTAL MONTHLY PREMIUM

Current/Recent Coverage:

Current Drug Cost(s):

$

TOTAL MONTHLY DRUG EXPENDITURE

Offered employer coverage?

Total | Current Monthly Spending:

👍 What do you like about your current plan?

👎 What do you NOT like about your current plan?

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Let's talk a little about you...

Pre-Existing Conditions:

Select any current or recently diagnosed illness's

None
High BP 🩸
High Cholesterol
Heart Attack 🫀
Stroke 🧠
Cancer
Asthma 🫁
COPD 🫁
Arthritis 🦴
Injury 🩼
Disabled ♿
Kidney Disease
Other
Diabetes 💊
Diabetic 💉
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Other Pre-Existing Conditions:

👩‍⚕️ PCP:

🦷 Preferred Dentist:

🏥 Preferred Hospital:

🏩 Preferred Pharmacy:

Additional Notes 🖊️

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