• 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
Arch Brokerage Arch Brokerage Arch Brokerage Arch Brokerage
  • 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

"*" indicates required fields

Client Name*
Please enter one entry for each spouse
MM slash DD slash YYYY
Address*

Please select below the type of product(s) you want the agent to discuss.
Stand-alone Medicare Prescription Drug Plans (Part D)
Medicare Advantage Plans (Part C) and Cost Plans
Dental/Vision/Hearing Products
Supplemental Health Products
Medicare Supplement (Medigap) Products

Prescription Drug(s) Currently Prescribed

Substitute Generics for Brand?
Switch Pharmacies to Save?
Please estimate the amount of medication by considering how often the prescription is refilled. If you are taking insulin, inhalers, creams, or lotions, please specify (number of pens, vials, inhalers, bottles, tubes, etc.) per month or year. Please do not list any over the counter medications (medications you can purchase without a prescription).
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
 


PHONE

FAX

EMAIL

LOCATION

(314) 849-6363

(314) 849-9292

[email protected]

8084 Watson Rd # 100,
St. Louis, MO 63119

Employee Benefit Plans Individual CoverageMedicare
AboutContact

Connect on LinkedIn    

Get Directions    

Privacy Statement | Copyright © 2022 Arch Brokerage Inc. | BeanstalkWebSolutions

  • Medicare Overview
  • Medicare Supplements
  • Medicare Advantage Plans
  • Prescription Drug Plan
  • Life Insurance
  • Annuities
  • Long Term Care Insurance (LTC)
  • Dental Benefits
  • Vision Benefits
  • Travel Policies