Get a Quote In order for us to know what solution fits you best, please take a few minutes and complete the appropriate planning form.We look forward to speaking with you soon! Planning Forms: Medicare Plans Medicare Intake Form Name * First Name Last Name DOB * MM DD YYYY Gender * Male Female Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Annual Income * $ Are you still working? * Yes No Are you enrolled in Social Security? * Yes No Are you a Veteran? * Yes No Are you on Medicaid? * Yes No Have you been offered Retiree Coverage through a previous employer? Yes No Current Medications * Please type the full name, dosage & frequency Current Providers * Please list your primary care physician and all specialist. How did you hear about us? Thank you! Health Insurance Health Care Planning Form Name * First Name Last Name Gender * Male Female DOB * MM DD YYYY Phone (###) ### #### Email * Income Covered California offers rates on health insurance directly related to your income. Please let us know your estimated yearly income and we can more accurately price your health insurance plan. $ Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Who else can we help? * List all additional family members you would like to insure. Please include their DOB. How did you hear about us? Thank you! Long-Term Care Long-Term Care Planning Form Name * First Name Last Name Gender * Male Female DOB * MM DD YYYY Phone * (###) ### #### Email * Marital Status * Married Single Widow Spouse's Name First Name Last Name Spouse's DOB MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Net Worth Under $500,000 $500,000 to $1,000,000 $1,000,000 to $1,500,000 $1,500,000 to $2,500,000 $2,500,000 to $3,000,000 Over $3,000,000 Income Under $50,000 $50,000 to $100,000 $100,000 to $150,000 $150,000 to $200,000 $200,000 to $250,000 Over $250,000 Health Status * Long-Term Care insurance requires each applicant's health to be underwritten. Please list any health concerns as well as appointments & tests that have not been completed for each applicant. How did you hear about us? Thank you! our mission“Like a good shepherd protects and guides, we wish to do the same for you and your family.”
