Medicare Fact Finder Client - Jeff Latall | Arch Brokerage

Complete the medical fact finder to jump start your application process

Your answers are secure and confidential.
Client
Name
First Last
Email
Existing Arch Brokerage Customer?
- I am an existing Arch Brokerage customer
Date of Birth
Month
Day
Year
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Gender
- Male
- Female
County
Enter the County the City/Town is located in
Phone
Medicare Part A Effective Date
MM slash DD slash YYYY
Medicare Part B Effective Date
MM slash DD slash YYYY
Retirement Effective date
MM slash DD slash YYYY
Current plan coverage & monthly premium:
Smoker? (please enter Yes or No)*
How did you hear about us?
Do you have a medicare.gov account?
- Yes
- No
Medicare.gov Username:
Medicare.gov Password:
If you do not have a medicare.gov account, do you give Arch Brokerage permission to set one up on your behalf?
- Yes
- No

Client
9. Prescribed Drug
Dosage

Include numbers only please.
Frequency
10. Prescribed Drug
Dosage

Include numbers only please.
Frequency
11. Prescribed Drug
Dosage

Include numbers only please.
Frequency
12. Prescribed Drug
Dosage

Include numbers only please.
Frequency
13. Prescribed Drug
Dosage

Include numbers only please.
Frequency
14. Prescribed Drug

If you don’t know the dosage, such as “500” mg, you may leave it blank. Include numbers only please.
Dosage

Include numbers only please.
Frequency
15. Prescribed Drug
Dosage

Include numbers only please.
Frequency
Additional Information
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

Your answers are secure and confidential.