fax: (972)546-0501

Please take a few moments to complete this form so that I may better serve you:

Health Insurance Needs Assessment 


                    Contact:     
                    Email Address:      
                    Phone Number:       
                    Zip Code:           

                                        **  COVERAGE TYPE REQUESTED  **
                               Family  Individual  Group (2-50 employees)
                                         

                    Please check all that fit your circumstances.
                     

                    I am currently unemployed and have no access 
                       to group coverage, Medicare or Medicaid.
                    I am currently self-employed and have no access 
                       to group coverage through another person.
                    I may change jobs in the near future. I want to 
                       explore my options now.     
                    I need health coverage for the next 6 months 
                       to one year.
                    I have questions about Medicare.
                    I have questions about Medicaid.
                    I'm shopping for a lower price.

                    Other reasons you are shopping for health insurance: 

                    


                    Please indicate your preference with respect to the following 
                    policy features:

                       Deductible: 

                            none
                            $500     
                            $1000   
                            $2500     
                            $5000     
                            $10000    
                            Other: 

                       Office Copay: 

                            none
                            $15     
                            $25   
                            $50   
                            Other: 

                       Coinsurance: 

                            none
                            50\50
                            80\20   
                            100\0   
                            Other: 


                       Total Out of Pocket (OOP): 


                            $1000
                            $2500     
                            $5000   
                            $10,000     
                            $20,000 
                        
                            Other: 


                       Lifetime Benefit: 

                            $500,000
                            $1,000,000
                            $2,000,000   
                            $5,000,000   
                            Other: 

                      
                    Please enter any comments or questions you may have in the 
                    following box:
Office Copay: A fixed fee that you pay when you visit a doctor's office.  Usually, this benefit is available immediately upon policy issue and is not included in your deductible.  Plans with a lower premium also have a lower or no Office Copay.
Deductible:  The amount of covered charges you must pay before the insurance company starts paying.  The higher the deductible, the lower your premium will be.