COVERAGE ASSESSMENT

It's helpful to gather the following information so you can find the best coverage. Help us understand your current healthcare needs by answering the following questions:

First Name

Last Name

Phone

Date coverage is needed:

Primary Care Provider Name (PCP):

Primary Care Provider Zip Code:

About how many times do you visit your Primary Care Doctor per year?

1-3 times per year

3-6 times per year

7 or more times per year

Do you see any specialist doctors?

Yes (if yes, please provide details in next section)

No (if no, skip next section)

1) Provide Specialist Doctor Name and Zip Code:

About how many times do you visit this specialist per year?

1-3 times per year

3-6 times per year

7 or more times per year

2) Provide Specialist Doctor Name and Zip Code:

About how many times do you visit this specialist per year?

1-3 times per year

3-6 times per year

7 or more times per year

3) Provide Specialist Doctor Name and Zip Code:

About how many times do you visit this specialist per year?

1-3 times per year

3-6 times per year

7 or more times per year

How many prescription medications do you currently take on a monthly basis?

Please provide the prescription name, dosage and and frequency for all medications you take:

Do you have out-of-state providers?

Yes

Do you qualify for Rx Extra Help and/or Medicaid?

Yes

Additional services that interest you: (select all that apply)

Acupuncture

Caregiver reimbursement

Dental services

Hearing aid

Hearing exams

Meals

National gym membership

Over-the-counter benefit (OTC)

Transportation

Vision exam

Vision hardware

Wellness reimbursement

Thanks for submitting!

EAGLE INSURANCE

info@eagleinsuranceco.com

401-239-3992

75 Newman Avenue Suite L1, East Providence, Rhode Island 02916