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Insurance Intake Form

Please complete the form below so I can prepare accurate insurance options for you.

This intake helps me match you with the best Health, Dental, Vision, Hearing, and Supplemental plans available. Your information is secure and never shared.

Before your appointment, please complete the Insurance Intake Form. This allows me to prepare your quotes ahead of time so everything is ready when we meet.

HELMS Signature Solutions

INSURANCE INTAKE FORM

Health • Dental • Vision • Hearing • Supplemental

Basic Information: Full Name: *

Phone Number: *

Date of Birth: *

Email Address: *

Home Address: *

Preferred Contact Method: *

Phone
Email
Text

Household Details

Number of People in Household: *

List Household Members & DOBs: *

Anyone Else Needing Coverage? *

Yes
No

Coverage You’re Interested In (Check all that apply) *

Health Insurance (ACA Marketplace)
Dental Insurance
Vision Insurance
Hearing Coverage
Supplemental Coverage:
Accident
Critical Illness
Hospital Indemnity

Current Coverage *

Do you currently have health insurance? *

yes
no

If yes, what type? *

Do you have dental or vision coverage? *

yes
no

Do you have any supplemental plans? *

yes
no

Provider Preferences

Preferred Doctors/Clinics: *

Preferred Hospitals: *

Preferred Pharmacies: *

HOUSEHOLD INCOME (ACA Purposes)

Estimated Yearly Household Income: *

Income Source: *

Employment
Self‑Employed
SSI/SSDI

Other: *

Special Enrollment Questions *

Lost Coverage
Moved
Marriage
Divorce
New Baby

Other Event: *

Additional Notes

Other Information or Comments: *

Consent to Contact

By submitting this form, you agree that Helms Signature Solutions may contact you regarding your insurance options.

📞 (573) 604‑5738 ✉️ ChristopherHelms@HelmsSignatureSolutions.com 🌐 www.HelmsSignatureSolutions.com

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