JRB Insurance LLC - Dental, Vision & Hearing Profile

You & how to reach you

Basic contact details so James can follow up once he's compared plans.

Last name

First name

M.I. (optional)

Date of birth

Email

Phone

Home street address (plan availability and pricing vary by area)

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.

Whose profile is this?

My own My spouse's Someone else's

Please select one option.

Dental profile

Type "N/A" in any box below that truly doesn't apply.

Do you currently have dental coverage?

Yes No Not sure

Please select one option.

When was your last dental cleaning or exam?

How often do you typically go?

Do you have a current dentist you'd want to keep?

Any dental work you're anticipating or have been told you'll need? (select all that apply)

Please select at least one option.

Anything else about your teeth or gums James should know?

Vision profile

Type "N/A" in any box below that truly doesn't apply.

Do you currently have vision coverage?

Yes No Not sure

Please select one option.

Do you wear glasses or contacts?

Glasses Contacts Reading glasses only Neither

Please select at least one option.

When was your last eye exam?

How often does your prescription tend to change?

Any diagnosed eye conditions? (select all that apply)

Please select at least one option.

Preferred eye doctor or retailer, if any

Anything else about your eyes or vision James should know?

Hearing profile

Type "N/A" in any box below that truly doesn't apply.

Do you currently have hearing coverage?

Yes No Not sure

Please select one option.

When was your last hearing test?

Have you been diagnosed with hearing loss?

Do you currently use hearing aids?

Yes, happy with them Yes, want to upgrade No, but may need them soon No, don't anticipate needing them

Please select one option.

Anything else about your hearing James should know?

Priorities & budget

This is what actually decides whether a bundled plan or separate standalone plans make more sense for you.

Which matters most to you, honestly? (select your top priority)

Dental Vision Hearing All about equal

Please select one option.

How would you describe your comfort with monthly premium vs. out-of-pocket cost?

Lowest premium possible Higher premium, lower costs at time of care Somewhere in the middle

Please select one option.

Roughly what monthly budget did you have in mind for dental/vision/hearing combined?

Would you rather have one bundled dental/vision/hearing plan, or separate standalone plans?

One bundled plan Separate standalone plans Whatever James recommends

Please select one option.

Anything else that would help James compare plans for you?

Anything else you'd like to look at?

Totally optional, and checking a box here doesn't commit you to anything — it just tells James what to bring up next time you talk. He'll send you the right form for whatever you pick.

I'd also like information about:

Medicare Individual/family health (ACA) Annuities / retirement income Life insurance Long-term care Social Security analysis Nothing else right now

Let's map out your dental, vision & hearing needs

You & how to reach you

Dental profile

Vision profile

Hearing profile

Priorities & budget

Anything else you'd like to look at?

Your summary