Employee Benefit Plans
Employee Benefit Plans Overview
Group Health Plans
Life Benefits
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Accidental Death
Long Term Care Insurance (LTC)
Disability Benefits
Medicare
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Annuities
Long Term Care Insurance (LTC)
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Individual Coverage
Individual Coverage Overview
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Vision Benefits
Travel Policies
Forms
Medicare Fact Finder – Client
Individual Fact Finder
Prescription Drug Fact Finder
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
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
Scope of Appointment
Arch Financial
About
Contact
"
*
" indicates required fields
Client Name
*
Please enter one entry for each spouse
First
Last
Date of Birth
MM slash DD slash YYYY
Email
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
Please select below the type of product(s) you want the agent to discuss.
Stand-alone Medicare Prescription Drug Plans (Part D)
Yes
No
Medicare Advantage Plans (Part C) and Cost Plans
Yes
No
Dental/Vision/Hearing Products
Yes
No
Supplemental Health Products
Yes
No
Medicare Supplement (Medigap) Products
Yes
No
Prescription Drug(s) Currently Prescribed
Substitute Generics for Brand?
Yes
No
Preferred Pharmacy
Switch Pharmacies to Save?
Yes
No
Current Prescription Drug Plan Name
If you are taking insulin, inhalers, creams, or lotions, please specify the number of pens, vials, inhalers, bottles, tubes, etc. taken per month or year. Please do not state "as needed" as we need an approximate quantity to provide an accurate review.
Form can accommodate up to 15 drugs and will automatically add additional drug lines if needed.
Please do not list any over-the-counter medications.
1. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
2. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
3. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
4. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
5. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
6. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
7. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
8. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
9. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
10. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
11. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
12. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
13. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
14. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
15. Name of Drug
Dosage (mg/ml)
Frequency (How often do you take this medication?)
Please select
daily
weekly
monthly
every 2 months
every 3 months
every 6 months
every 12 months
Quantity
Please select
1
2
3
4
5
6
15
30
60
90
180
270
360
450
540
Other (Please Specify in Additional Information)
Hidden
Prescription Drug Information
Please click + icon to add more drugs. If you don’t know the dosage, such as “500” mg, you may leave it blank. Only include numbers in the Dosage field.
Name of Drug
Dosage (Mg or ML)
Frequency
Add
Remove
Additional Information
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