Fact Finder

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Please complete this confidential form so I can prepare personalized coverage options for you. Skip anything that doesn’t apply to you, or you’d rather discuss by phone. Your information is secure—never shared. No obligation to enroll.

Name

Fill your name in exactly as it appears on Medicare Card if applicable. Add middle name or initial in same block as first name.

First Name

Last Name

Date of Birth

YYYY

Phone

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medicare Number if applicable

Medicare Part A Effective Date

YYYY

Medicare Part B Effective Date

YYYY

Doctor List

List each doctor on a new line. Example: Dr. Smith – Primary Care - Erie, PA Dr. Jones – Cardiologist - Charlotte, NC Dr. Lee – Dentist - Oil City, PA

Current Prescriptions

Please list each prescription on a new line with: Name of medication (brand or generic) Dose (strength) How often you take it ❌ Do not include over-the-counter medications or Part B drugs given at a medical facility. Example: Lisinopril – Generic – 10mg – 1x daily Metformin – Brand – 500mg – 2x daily Atorvastatin – Generic – 20mg – 1x nightly

What services are you interested in?

Medicare

Health Insurance For Under Age 65

Hospital Indemnity

Cancer Coverage

Dental, Hearing, Vision

Life Insurance

How did you hear about us?

Notes/Special Request

By clicking “Submit Fact Finder,” I agree that MCJ Insurance may contact me by phone, text, or email about insurance options. Permission to contact only — no obligation. Opt out anytime.

Fact Finder

Let’s work together!

MCJ INSURANCE

Location

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