• 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)

  • Do you currently have health insurance?*
  • If we found you something affordable, would you like to see it?
  •  -
  • Continue with Level 2 Lead?*

  • Survey cont. - (Level 2 Lead)

  • Are you employed?*
  • Does your employer offer health insurance coverage?
  • Are you married?*
  • Is your spouse employed?*
  • Does your spouse's employer offer health insurance coverage?
  • Do you have any dependents?
  • Continue to Level 3 or 4 lead?*
  • Which type of insurance are you interested in? Select all that apply.

  • Additional Personal Information

  • DB
     - -
  • Tobacco Use?
  • Gender
  • US Citizen?

  • Additional Spouse Information

  • Spouse - DB
     - -
  • Spouse - Tobacco Use?
  • Spouse - Gender
  • Spouse - US Citizen?
  •  -

  • Additional Dependent Information

  • Dep #1 - DB
     - -
  • Dep #1 - US Citizen?
  • Dep #1 - Lives at Home?
  • Dep #2 - DB
     - -
  • Dep #2 - US Citizen?
  • Dep #2 - Lives at Home?
  • Dep #3 - DB
     - -
  • Dep #3 - US Citizen?
  • Dep #3 - Lives at Home?
  • Dep #4 - DB
     - -
  • Dep #4 - US Citizen?
  • Dep #4 - Lives at Home?
  • Dep #5 - DB
     - -
  • Dep #5 - US Citizen?
  • Dep #5 - Lives at Home?
  • Are there any serious health issues that require treatment?

  • Employment & Financial Information

  • Will you be claimed by anyone as a dependent for tax purposes?
  • Did you complete your taxes for 2016/2017?

  • If married, will you file your income taxes jointly?
  • Do you currently pay or receive alimony?
  • Pay or receive?
  • Do you currently receive disability?
  • Enter PI?
  • TA
  • Enter Referrals?
  •  -
  •  -
  •  -

  • 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.

  • Signature
  • Should be Empty: