New to Medicare Questionnaire (Adult)

Emergency Assistance

If this is an emergency, call:

So that we may provide the best possible result fill in what you know. If you don't have everything yet, that's okay.

Let us know how we may be of service:

Client Information

First name

Last name

Home Address

Home City

Home Zip Code

Main phone number

Best time to call

Email address

Birthdate

Date expected to Start Medicare?

Are you currently covered by an employer plan? If yes provide the carrier plan information.

Company Name

How many employees for for your employer?

If you're not sure ask your HR person or supervisor.

Are you planning to work after turning 65? If so how long?

Is Elite Benefits the broker for the company?

We offer many plans.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Has a prescription list been obtained?

Upload a copy of the insurance card, letter of coverage, Rx List etc.

Add file

Please upload a file

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