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
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
Prescription Drug Fact Finder
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
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
Prescription Drug Fact Finder
About
Contact
Step 1 of 4
25%
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
MM
DD
YYYY
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
Date Format: MM slash DD slash YYYY
Medicare Part B Effective Date
Date Format: MM slash DD slash YYYY
Retirement Effective date
Date Format: MM slash DD slash YYYY
Current plan coverage & monthly premium:
Smoker? (please enter Yes or No)
*
How did you hear about us?
Client
PHYSICIANS
Primary Care
Specialist
Specialist 2
Specialist 3
Specialist 4
Hospital Preference
Prescription Drug(s) Currently Prescribed
Substitute Generics for Brand?
Yes
No
Preferred Pharmacy
Switch Pharmacies to Save?
Yes
No
1. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
2. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
3. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
4. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
5. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
6. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
1 time per day
1 time per day
weekly
as needed
other
7. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
8. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
Client
9. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
10. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
11. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
12. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
13. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
14. Prescribed Drug
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
15. Prescribed Drug
Dosage
If you don’t know the dosage, such as “500” mg, you may leave it blank.
Include numbers only please.
Frequency
1 time per day
2 time per day
3 time per day
weekly
as needed
other
Additional Information
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
Privacy Statement
| Copyright © 2021 Arch Brokerage Inc. |
BeanstalkWebSolutions
