Individual Policy Questionnaire

Please complete the form below and one of our team members will reach out to you with our findings. Please know that we would love the opportunity to help you out, but only if it makes sense. If you have a great employee benefits program for your staff, then we'll tell you.

As always, if you need to speak to us immediately, please call us at (614) 326-7356.

Today's Date

MM

DD

YYYY

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Spouse Date of Birth

MM

DD

YYYY

Estimated Household Income

Is Employer Coverage Available?

Name of Employer

List Dates of Birth & Gender for Dependents 20 and Under:

List Dates of Birth & Gender for Dependents 21 - 26:

Tobacco Usage - Answer Yes or No and Who uses:

Name and Affiliation of Doctors:

List Prescription Medications:

Preferred Hospital

Preferred Pharmacy

CONFIDENTIALITY NOTICE: This form, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and priveleged information or which may otherwise be protected by law. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact Cor-Ben Consultants and destroy all copies.

IRS Circular 230 disclosure (pursuant to U.S. Treasury Regulations governing tax practitioners): Any tax advice contained in this communication (including any attachments or enclosures) was not intended to be used for the purpose of (i) avoiding penalties under the Internal Revenue Code, or (ii) promoting, marketing or recommending to another party any transaction or matter addressed in this communication.