Secure Insurance - Medicare Health Plan Request Form

You & how to reach you

Basic contact details, plus a quick profile of your own coverage needs.

Last name

First name

M.I. (optional)

Date of birth

Email

Phone

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.

Will you (the person filling out this form) be covered on the plan we're researching?

Yes No – covered elsewhere Not sure

Please select one option.

Do you currently have health coverage?

Yes No

Please select one option.

Tobacco use (select N/A if under the legal age to purchase tobacco)

Yes No N/A – under legal age

Please select one option.

Special circumstances: are you a parent or legal guardian of a child under age 19?

Yes No

Please select one option.

Your doctors, medications & expected care

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

Doctors, specialists, or hospitals you want to keep

Regular prescription medications (name + dosage if known)

Preferred pharmacy (name and location)

Do you use mail-order for any of your prescriptions?

Yes No Not sure

Please select one option.

Anything expected in the next 12 months that affects your care needs?

Planned surgery/procedure Pregnancy / planning Ongoing specialist care New to the area N/A – none of the above

Please select at least one option (or N/A).

Anything else about your health care needs?

Medicare details

If you're not currently exploring Medicare, select "N/A" throughout this section.

Medicare number (if you have one - optional)

Are you already enrolled in Medicare Part A (hospital)?

Yes No Not sure N/A

Please select one option.

Are you already enrolled in Medicare Part B (medical)?

Yes No Not sure N/A

Please select one option.

Are you currently collecting Social Security?

Yes No Applied – waiting to start Not sure

Please select one option.

Your comfort level

Just a gut-check so I know how much explaining to do — there's no wrong answer.

Comfort with Medigap (Medicare Supplement) rules (1 = not at all, 10 = very comfortable)

Comfort with Medicare Advantage rules (1 = not at all, 10 = very comfortable)

Vision, dental & hearing

Do you need any of the following? (select all that apply)

Vision Dental Hearing None needed

Please select at least one option (or "None needed").

Household & income

This helps me understand your income picture, including whether IRMAA (an income-based Medicare surcharge) may apply.

Most recent employer

If you're retired or not currently working, use your most recent employer. Type "N/A" in any box that truly doesn't apply.

Employer name

Employer phone number

Employer address

Estimated total household income for the coverage year (gross, before taxes)

Any income that varies or is hard to estimate? (self-employment, tips, seasonal work, etc.)

Which IRMAA income bracket applies to you? (based on your most recent tax return - approximate 2025 figures, select your best guess)

Other household members

Add everyone else who lives in your household or will be considered for coverage. If it's just you, you can skip this and continue to the next section.

Reason for shopping

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.

Budget & plan preferences

There's usually a trade-off between monthly premium and how much you'd pay when you actually use care. This tells me where you'd rather flex. If something doesn't apply, choose N/A.

Comfortable monthly premium

Comfortable with a higher deductible in exchange for a lower premium?

Any carriers you'd like me to prioritize? (select all that interest you)

Blue Cross Blue Shield of MI

Priority Health

Health Alliance Plan

UnitedHealthcare

Physicians Mutual

—

No preference

Please select at least one option (or "No preference").

Anything else?

Use this space for anything not covered above. If nothing else applies, type "N/A."

Let's find the right plan for you

Build a link for your client

You & how to reach you

Your doctors, medications & expected care

Medicare details

Your comfort level

Vision, dental & hearing

Household & income

Most recent employer

Other household members

Reason for shopping

Budget & plan preferences

Anything else?

Your summary