Health Lead Survey

Health Lead Survey
Agent Information
This is NOT a referral. This Health Lead Survey / Client Data Sheet is for the use of agents who wish to receive an emailed record of the client data entered into this form. This is NOT a referral; this is for your direct use with current/potential clients that you will directly follow up with.
Type of Lead *
Name of Referring Agent/Marketer

First Name Last Name
Agent Name

First Name Last Name
Agent Email Address *
This is the email address that the lead/client data will be emailed to.

Survey (Level 1 Lead)
Do you currently have health insurance? *

Yes No
If we found you something affordable, would you like to see it?

Yes No
Your Name *

First Name Middle Name Last Name
Phone Number *

Area Code Phone Number
Location *
Continue with Level 2 Lead? *

Yes No

Preferred Plan
Preferred Budget
Best Time to Call
Disclosure and Consent Agreement: If {agentName3} (Agent) /Peek Performance Insurance helps me find a plan that I like and can afford, I am giving my consent for this agent/agency to apply on my behalf for the programs/products that we have discussed. I wish for Peek Performance Insurance / {agentName3} (Agent) to be my Agent(s) of Record for 365 days/Calendar year of 2019 for my chosen health plan, and I wish for this/these agent(s) to be my Authorized Representative(s) so that he/she may speak to healthcare.gov, insurance carrier or other appropriate representatives on my behalf to provide documentation, ask and answer questions, make payments, etc. By consenting to this agreement, I authorize Peek Performance Licensed Insurance Agent/Agency, {agentName3}, its affiliates, employees and agents, to use the confidential information on this form that I have provided by phone and/or on this document only for the purposes of determining eligibility for healthcare coverage subsidy, enrollment in healthcare and/or related government assistance or other insurance plans or non profit health programs, and in making application for healthcare program or coverage and other insurance products. I give my permission for the above mentioned entities/persons to contact me for the purposes of further determining eligibility, educating me on health and other insurance options and/or setting an appointment or means to review and/or sign an application for insurance. I understand that no confidential/private information will be shared with any outside entity other than those described above.
I agree to the above disclosure and sign below.
Name

First Name Middle Name Last Name
Signature
Should be Empty:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Agent Information

Survey (Level 1 Lead)

Survey cont. - (Level 2 Lead)

Additional Personal Information

Additional Spouse Information

Additional Dependent Information

Employment & Financial Information