JRB Insurance LLC - Client Profile

What would you like help with today?

Check everything you want to talk about. You can always come back to this exact link later and add more.

Select everything that applies

Health Insurance (ACA Marketplace) Medicare Dental, Vision & Hearing Annuities / Retirement Income Social Security Analysis

Please select at least one topic.

You & how to reach you

This is shared across everything below — you only fill it out once.

I've already given James this information — skip this section

Last name

First name

M.I. (optional)

Date of birth

Mobile phone

Home phone (optional)

Work phone (optional)

Email for insurance correspondence (where carriers and confirmations should go)

Additional email address (optional — cc'd on nothing automatically, just on file)

About your Social Security number: we don't ask for it here, on purpose. It isn't needed to research plans or quote you — it's only required at the point of application, and at that stage we'll collect it directly with you, either on the phone or in the carrier's own secure enrollment portal. That keeps it out of email and off this website entirely.

Home street address

City

State

ZIP code

County

Preferred way to be contacted (select all that apply)

Phone call Text Email No preference

Please select at least one contact method.

Household members / dependents

Add anyone else — spouse, kids, etc. — who might need coverage or should be on file.

Timing

Health / Medicare

I've already given James this information — skip this section

Helps me understand the timing and whether you qualify for a special enrollment period.

Why are you shopping for a new plan right now?

Month you need coverage to start

Year

Coverage starts on the 1st of the month you choose. If you're not certain, choose “Not sure yet” and we'll sort out timing together.

At tax time, do you typically get a refund or owe?

Usually get a refund Usually owe About even Not sure

Please select one option.

Roughly how much, most years? (optional)

Health insurance details

Health

I've already given James this information — skip this section

Medicare details

Medicare

I've already given James this information — skip this section

Dental, vision & hearing

DVH

I've already given James this information — skip this section

Annuity / retirement income details

Annuity

I've already given James this information — skip this section

Social Security details

Social Security

I've already given James this information — skip this section

If you're not currently exploring your Social Security decision, select "N/A" throughout this section.

Marital status

If married or divorced, how long? (approximate)

Are you currently collecting Social Security?

Yes No – not yet filed Applied – waiting to start

Please select one option.

If collecting, when did payments start? (month/year)

Monthly benefit amount, if known

If not yet collecting, what age are you currently planning to file?

Last year you had (or expect) earned income

Current year annual earnings, if still working

Do you (or your spouse) have a pension from work not covered by Social Security? (e.g. certain government or teacher pensions)

Yes No Not sure

Do you have children under 18 (or disabled) who might qualify for a benefit on your record?

Yes No

If yes, names and birth dates

Anything else about your Social Security decision James should know?

If you have your Social Security statement handy (from ssa.gov/myaccount), feel free to email it separately to jrbinsurancehelp@gmail.com — or we can pull it up together on a call. No need to upload it here.

Anything else?

Use this space for anything not covered above.

One profile, everything we're working on together

Build a link for your client

What would you like help with today?

You & how to reach you

Household members / dependents

Timing

Health insurance details

Your doctors, medications & expected care

Medicare details

Your comfort level

Vision, dental & hearing

Your doctors, medications & expected care

Most recent employer

Dental, vision & hearing

Dental profile

Vision profile

Hearing profile

Priorities & budget

Annuity / retirement income details

Financial snapshot

Existing annuity or retirement contracts

Goals and risk tolerance

Beneficiaries & final notes

Social Security details

Anything else?

Your summary