New Client Discovery Form

Primary Applicant

First Name

Last Name

Phone:

Gender:

Date of Birth:

🏠 Household Size*

Email:

Employment Status

Annual Income:

Citizenship Status:

Employer Name

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Client Type

Client Status

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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:

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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:

Other Pre-Existing Conditions:

👩‍⚕️ PCP:

🦷 Preferred Dentist:

🏥 Preferred Hospital:

🏩 Preferred Pharmacy:

Additional Notes 🖊️

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