Your Health Coverage Profile

Let's see what you qualify for

Before your appointment with Kimberly, we'd like to learn a little about your health history so we can find the plans that are the best fit for you and your family. This takes about 5 minutes. Your answers are completely confidential and are used only to match you with the right coverage options.

Answer as accurately as possible — the more we know, the better we can help you

YOUR INFORMATION

Full Name *

Phone *

Email *

Date of birth *

Address

Street Address

City

State

Country

Postal Code

Step 1 of 7

HOUSEHOLD MEMBERS

Will anyone else in your household need coverage? Add them below.

Household Member 1 — First Name

Date of Birth

Relationship

Household Member 2 — First Name

Date of Birth

Relationship

Household Member 3 — First Name

Date of Birth

Relationship

Household Member 4 — First Name

Date of Birth

Relationship

Step 2 of 7

CURRENT MEDICATIONS

Please list all medications currently being taken by anyone in your household who will be on this plan.

Medication 1:

Person Name

Medication Name

Dosage

Condition Being Treated

Medication 2:

Person Name

Medication Name

Dosage

Condition Being Treated

Medication 3:

Person Name

Medication Name

Dosage

Condition Being Treated

Medication 4:

Person Name

Medication Name

Dosage

Condition Being Treated

Medication 5:

Person Name

Medication Name

Dosage

Condition Being Treated

Medication 6:

Person Name

Medication Name

Dosage

Condition Being Treated

Medication 7:

Person Name

Medication Name

Dosage

Condition Being Treated

Medication 8:

Person Name

Medication Name

Dosage

Condition Being Treated

Other Conditions

Q23: Are there any other health conditions, illnesses, or injuries in the past 5 years not listed above that a doctor is aware of?

Yes

No

Step 5 of 7

ONE LAST STEP — Your Signature

I confirm that all answers I have provided on this form are truthful, accurate, and complete to the best of my knowledge.

I understand that Kimsurance will use this information to recommend health insurance plans that are appropriate for my situation. I understand that misrepresentation or omission of health information may result in denial of coverage, rescission of a policy, or denial of claims by the carrier.

I agree that Kimsurance bears no liability for coverage issues arising from health information I have failed to disclose or have disclosed inaccurately.

Applicant Full Name *

Signature *

Clear

Step 7 of 7

If you have any questions before our meeting, please don’t hesitate to reach out.
You can contact us at [email protected]

Licensed and certified in 24 states for individuals, groups and Medicare. No international affiliations.

We proudly service the following US states only:

Arizona, California, Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, New York, Nevada, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia and Wisconsin.

Privacy Policy

Medicare Disclaimer: We do not offer every plan available in your area. We represent 5 of MA organizations, which offer 47 products in your area. Any information we provide is limited to those plans we do offer in your area. Please contact
Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.