FAMILY COMES FIRST

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Questionnaire Center
Click Here to Learn more about medicare

You may have a million problems—until you have a health problem.
Then you only have one!

❤️JM CARDIO LIFE

Wellness Division

Menu
Menu
Questionnaire Center
Click here to learn more about medicare

You may have a million problems—until you have a health problem. Then you only have one!

❤️JM CARDIO LIFE

Wellness Division

Menu

Questionnaire Center

Welcome to our Questionnaire Center!

Let's customize your request

Remember, every moment is a new opportunity to embrace life and all its possibilities!

Wellness Division: ❤️ Your Gut Check-Up
Wellness Division:
❤️Your Gut Check-Up
MEDICARE
TRAVEL PROTECTION
Dental Insurance
MEDICARE
Life insurance
Final Expenses
Retirement Planning
College Funding
Vision Insurance
Mortgage Protection
Debt Relief
Health Insurance (Family & Group Plans)
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Your Gut Health Check-In


Thank you for taking the first step in helping us understand your health. We’d love to learn more about your current wellness routine and how you’re feeling.

When your gut is out of balance, it can affect you physically, mentally, and emotionally.

Gut Health Check in
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Your Medicare Questionnaire

Hi, and welcome to your Medicare questionnaire! We’re so glad you’re here to start your Medicare journey with us. We’ll be more than happy to assist you every step of the way, ensuring you have a clear understanding—from reviewing your current plan to exploring new options that might benefit you in the coming year.

✅ IMPORTANT!

To provide you with a complete and accurate comparison, We need both Part A and Part B on this form. We want to ensure that we have all the information organized in one place, as it allows us to give you the best possible support and guidance. Your needs are important to us, and having both parts will help us provide a complete overview. Thank you!

✅Please read through the entire email, as it contains VERY IMPORTANT information. I look forward to receiving your information soon.

Medicare

PART A.

MEDICARE INFORMATION:

Did you know you can get penalized? Don't risk unnecessary penalties! We're here to help you enroll and save!

VERY IMPORTANT:

To help us focus on your most important Medicare needs and to ensure your Medicare coverage aligns with your current healthcare or if you decide to change plans, please provide the following details:

✅ The following will further assist us in better understanding your needs.

PART B.

Doctors' Information:

✅ While we make every effort to ensure that your doctors and prescriptions are in-network at the time of enrollment for the upcoming year, please keep in mind that providers and prescription medications may move in and out of network throughout the year.

 

✅  If you find that any of your doctors or prescriptions are no longer covered, I recommend discussing it with your doctor's office to explore options for staying in-network. This will help protect you from unexpected costs and ensure continuous coverage.

Please still provide us with the name and address of a preferred pharmacy near your zip code so we can check if it’s in network and ensure your protection, should you ever need it in the future.

Preferred Pharmacy and Address:

✅**If you have already completed or scheduled your Medicare Comparison Overview Appointment, please disregard the following information.
✅**Once we receive your information, please expect a response within 24 hours to schedule your Medicare Comparison Overview Appointment with me or one of my experts.
✅Please be advised that once your Medicare profile is completed with the information you provided, a Scope of Appointment (SOA) form will be sent to you via email. This form must be signed and returned before we can discuss any details of your Medicare plan in order to comply with CMS requirements. This step ensures that we, as agents, provide you with proper care when explaining your plans and options.
✅Thank you for your consideration; we truly appreciate it! If you have any questions, please let us know. We are here to assist you in any way we can.
 
☆ At Family Comes First Insurance Agency, your privacy is important to us, and we are committed to assisting you while protecting your personal information, as stated under HIPAA client protection. By providing your personal information, you consent to us contacting you for your insurance needs, including answering your questions, reviewing insurance plans, and providing quotes for the plans you choose. Once we apply for your chosen insurance plan and you are approved, we will share your details with the specific insurance carrier.
 
 
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Travel Protection Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Out of area protection - Travel Protection
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Dental Insurance Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Dental Insurance

**For family plans, some restrictions may apply.

Children must be under 26 years of age and living in the same household. If they are over 26, they can apply for their own plan.

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Life Insurance Questionnaire

Our insurance plans, including Life Insurance, allow us to turn care into action, protecting your family in meaningful ways!

Both term and permanent life insurance, each designed to meet different needs, offer vital support for your loved ones by providing unique benefits!

Life insurance doesn’t just provide security after the insured is gone; it also offers incredible benefits for the insured and their family while they’re together. From assisting with college funding and supporting retirement to providing living benefits if the insured is diagnosed with a critical, chronic, or terminal illness. Life insurance offers vital support for the insured and their loved ones throughout their journey together. In the insured’s absence, it can help their family pay off the mortgage, cover final expenses, and meet any other needs they may have.

You’re on this form because you want to take advantage of life insurance benefits and protect what matters most to you—your family!

Life Insurance Form

Health Information:

Health Information:

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Final Expenses (Funeral Service: Cremation & Burial) Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Final Expenses (Funeral Service: Cremation & Burial)
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Retirement Planning Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

RETIREMENT PLANNING (#7)
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College Funding Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

College Funding

For the Parents:

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Vision Insurance Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Vision Insurance

** For family plans, some restrictions may apply.

Children must be under 26 years of age and living in the same household. If they are over 26, they can apply for their own plan.

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Mortgage Protection Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

MORTGAGE PROTECTION
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Debt Relief Questionnaire

Please Fill Out The Form Below And We Will Get Back To You As Soon As Possible.

Debt Relief
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Health Insurance Questionnaire

Thank you for considering Family Comes First Insurance Agency for your insurance needs. To provide you with a customized health plan illustration, we kindly request the following information. We look forward to hearing from you soon. Thank you!

Health Insurance

Your Individual & Family Health Plan Questions

Please provide the following information for each person in your household that you are applying for:

Health Information:

Employer and Coverage Details:

Family Household Member Information

Please provide the following information for ALL family members that you are applying for. Kindly put N/A if not applicable.

Health Information:

Health Information:

Health Information:

Health Information:

Health Information:

✅  If you are applying for 6+ household members, please number each member and keep them in order as you answer the next set of questions. This helps ensure all information is clearly organized for each member.

Health Information:

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