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Scope of Appointment
Arch Financial
About
Contact
Employee Benefit Plans
Employee Benefit Plans Overview
Group Health Plans
Life Benefits
Dental Benefits
Vision Benefits
Accidental Death
Long Term Care Insurance (LTC)
Disability Benefits
Medicare
Medicare Overview
Medicare Supplements
Medicare Advantage Plans
Prescription Drug Plan
Life Insurance
Annuities
Long Term Care Insurance (LTC)
Dental Benefits
Vision Benefits
Travel Policies
Educational Video Series
2026 Fall AEP
Individual Coverage
Individual Coverage Overview
Health Insurance
Life Insurance
Annuities
Long Term Care Insurance (LTC)
Dental Benefits
Vision Benefits
Travel Policies
Forms
Medicare Fact Finder – Client
Individual Fact Finder
Annual Medicare Review Form
Scope of Appointment
Arch Financial
About
Contact
Individual Fact Finder
Name
First
Middle
Last
Email
Phone
Address Line 1
Address Line 2
Zip Code
City
States
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Gender
Male
Female
Date of Birth
Month
Day
Year
Marital Status
Single
Married
Divorced
Tobacco User?
Yes
No
Household Income Level
Required to determine if eligible for a subsidy.
Household Size (# of individuals on tax return)
Current Insurance Carrier
Current Monthly Premium
End Date of Current Coverage
Cost of Prescription Drugs
Coinsurance
Deductible
Are you an existing Arch Brokerage client?
Yes
No
How did you hear about us?
What hospital networks (BJC, Mercy, SSM, etc) – do you need to have access to?
Which, if any, doctors are essential to have in network?
List any ongoing medications you and your dependents currently take. Please specify the name, dosage, and which family member currently takes to the best of your ability.
If Spouse/Dependents are currently covered and/or you would like coverage for them, please complete the following:
Spouse Name
Gender
Male
Female
D.O.B.
Dependent 1
Gender
Male
Female
D.O.B.
Dependent 2
Gender
Male
Female
D.O.B.
Dependent 3
Gender
Male
Female
D.O.B.
Dependent 4
Gender
Male
Female
D.O.B.
Additional Information
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