Page 1 - Questionnaire
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Questionnaire
For people who want to compare their employer plan to Medicare options
Please send us your completed questionnaire by e-mail, FAX, or U. S. Mail:
E-mail: doverhealthcareplanning@gmail.com
Fax: (562) 498-7348
U. S. Mail: 461 Kakkis Drive, #102, Long Beach, CA 90803.
Or if you’d like to complete the questionnaire over the phone, please send us an e-mail to suggest
a time that is good for you, or call our office toll-free at (877) 236-7710.
Your Name and Mailing Address (including home zip code):
____________________________________________
____________________________________________
____________________________________________
The county you live in: ___________________________________
Your e-mail address: _________________________________________
If you wish to have a password for your evaluation, please enter it below:
________________________________________
A: Enrollment and eligibility questions
1. What is your date of birth? ______ ______ ______
Month Day Year
2. Are you already enrolled in Part A of Medicare? Yes No
3. When would you begin your Medicare (A+B) coverage? ______ ______ ______
Month Day Year
4. Are you currently receiving Social Security payments? Yes No
5. Are you making contributions to a Health Savings Account? Yes No
For Office Use
Client Number:
___________________
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