• Insurance and Other Red Tape - Bonnie Dobbs Agency

  • Today's Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Do you have Medicare?*
  • Part A Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Part B Effective Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Do you have Medicade?*
  • Select Full or Partial
  • Do you smoke? , Currently disabled? ... Click all that apply
  • Form is being completed by:
  • If Other,do you have Power of Attorney?
  • Format: (000) 000-0000.

  • If you want us to research drug plans, please provide the following information:

  • Enter Prescription Drugs Here:
  • If yes, when did you move there?
  • If yes, when did you move there?
     / /
    2 digit month, 2 digit day, 4 digit year
  • When?
     / /
    2 digit month, 2 digit day, 4 digit year
  • When?
     / /
    2 digit month, 2 digit day, 4 digit year
  • When?
     / /
    2 digit month, 2 digit day, 4 digit year
  • Will you have employer coverage through yourself or your spouse after you turn 65?
  • If Yes, does the company pay insurance for more than 20 employees?*

  • **If Yes, what is your individual portion of the monthly premium and annual deductible?

  • Do you make more than $97,000 a year if filing single, or more than $194,000 a year if filing jointly with spouse?

  • Do you make less than $1,843 a month and have less than $16,660 in assets/resources* if filing single, or make less than $2,485 a month with less than $33,240 in assets/resources if filing jointly? *Does not include your home, vehicles, personal possessions, life insurance or burial plots/contracts.

  • When finished, select SUBMIT to send the form to our office. Thank you, we look forward to working with you.

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