Roadmap Questionnaire Roadmap Questionnaire Are you an agent or advisor? * Yes No First Name * Last Name * Phone Email * Are you a US Citizen/Permanent Resident AND have you OR your spouse worked at least 10 years for which you paid Medicare taxes? * Yes No Current Age * Turning Age 65 Soon Over Age 65 Under Age 65, but qualified for SSDI/Medicare (disabled) Qualifying for Medicare due to Kidney Conditions or ALS Current Coverage * Group Insurance-offered by my/spouse's current or previous employer Individual Insurance-ACA/Obamacare Retiree Plan COBRA Severance Benefits No Current Insurance I don't know Employment Status of Primary Insured * Will continue working at employer providing benefits Will stop working (or already stopped working) at the employer providing benefits The primary insured on your plan is the main subscriber on the insurance policy (the employee holding the coverage). If you are a dependent on your spouses group plan, your spouse is the primary insured. Future Coverage * I will be coming off group benefits I have access to a Retiree Plan I have access to COBRA I am offered Severance Benefits I don't know Once you are no longer working at the employer providing benefits Number of Employees (at the Company providing your current group benefits) * 2-19 20-99 100+ Do you contribute to a Health Savings Account? * Yes No Submit