INDIVIDUAL / FAMILY HEALTH INSURANCE QUOTE (Customized & personalized) ALL INFORMATION IS CONFIDENTIAL
APPLICANT APPLICANT SPOUSE 
First Name: First Name:
Last Name: Gender: Smoker:
Telephone Number (10-Digits): Age: Plastic Surgery: Body Part:
Email Address:
INSURANCE & ANNUITIES
INCOME PLANNING
EMPLOYEE BENEFIT PLANS
BUSINESS PLANNING
Is current coverage through an Employer Plan?
Do you currently have a Physician you don't want to lose? .
NOTES: Please list below any health issues, medications (Including dosages & frequency) or any pertinent notes below!
Type of Plan:
Resident City:
Currently on Medicare:
Transitioning to:
Resident State:
Resident ZipCode:
WANT TO TAKE ACTION ON:
Are you self-mployed?
Gender:
Smoker:
Date of Birth:(Ex. 01/01/2000)
Plastic Surgery:
Body Part:
Height:
Weight:
Currently on Medicare:
Transitioning to:
Currently Insured:
What Company?
If YES, Full Name:
Phone Number:
I was referred by:
Desired Effective Date:
Being treated for any health issues?
If Yes, list in NOTES
Being treated for any health issues?
If Yes, list in NOTES
Need a Tax Write-Off:
Ages:
APPLICANT CHILDREN
M / F:
Insurance
Annuities
Retirement Income
Tax Avoidance Strategies
Your INDEPENDENT Resource
949.954.4445
Weight:
Self-Employed:
Height:
THE FOLLOWING WILL NEED TO BE ANSWERED FOR COVERAGE STARTING 1/1/2020 .
What is your expected *Personal Adjusted Gross Income (AGI) this year? Example: $46,000
What is your expected **Household Adjusted Gross Income (AGI) this year? Example: $94,000
*Adjusted Gross Income (AGI) =
THE SUM OF: Wages, salary tips + Taxable Interest + Ordinary Dividends + Net Capital Gains/ losses + Total IRA Deductions (Only th taxable amount) + Pensions, annuiities (Only the taxable amount) + Other (Include as "other" any income you may have received from your business; alimony; unemployment compensation; rental real estate; royalties, partnerships, S corporations and trusts; farm income; and any taxable Social Security benefits. Also include taxable refunds, credits, or offsets in state and local income tax. DOES NOT INCLUDE:gifts and inheritances, tax-free Social Security benefits and tax-free interest from state or local bonds.
MINUS:
THE SUM OF: IRA contributions + Student loan interest + Moving expenses + One-half of self-employment tax + Self-employed health insurance contribution + Contributions to SEP, SIMPLE and qualififed plans for yourself + Other (any alimony paid, deductions for Archer Medical Savings Accounts, and penalties paid on early withdrawal of savings)
**The sum of Personal Adjusted Gross Income for all dependent family members living under the same household.
NOTE: The above is an approximation and actual Adjusted Gross Income is deteremined by the Internal Revenue Service (IRS) and is subject to change !
