Health Lead Survey - Agent Version Logo
  • 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.

  • Survey (Level 1 Lead)

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  • Survey cont. - (Level 2 Lead)


  • Additional Personal Information

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  • Additional Spouse Information

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  • Additional Dependent Information

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  • Employment & Financial Information


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  • 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.

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