Jody Lloyd Insurance
Home
About
Insurance Types
Contact
Home
About
Insurance Types
Contact
Get An Insurance Quote
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 3
Gender
Male
Female
Other
Marital Status
Married
Single
Civil Partnership
Common-Law
Cohabiting
Divorced
Separated
Widowed
Next
What type of Insurance do you want?
*
Life Insurance
Health Insurance
Medicare
Do you already have an Insurance
Yes
No
Next
Cover Amount for Life Insurance
Policy Duration for Life Insurance
In the last 5 years have you had any of these?
*
Depression
Anxiety
Stress
Any Other Mental Health Issue
None of these
Have you ever had any of these?
*
Eating Disorder
Bipolar Disorder
Manic Depression
Schizophrenia
Psychosis
None of these
In the last 5 years have you had any of these?
*
Raised blood pressure, cholesterol, or chest pain
Diabetes or raised blood sugar
Anemia, blood clot, or anything else affecting your blood
A growth, lump, or cyst
Asthma, sleep apnoea, or anything else affecting your lungs or breathing
Kidney stones, urinary infection or anything else affecting your kidneys, prostate, bladder or urine
Back pain, sciatica, whiplash or anything else affecting your back or neck
Impaired, blurred or double vision, optic neuritis or anything else affecting your eyes
None of these
Cover Amount for Health Insurance
Policy Duration for Health Insurance
Have you had or been treated for any of the following conditions in the last 5 years?
*
High blood pressure or hypertension
High cholesterol
Diabetes or prediabetes
Asthma, COPD, or any chronic lung condition
Heart attack, stroke, or other heart-related conditions
Cancer or tumor (benign or malignant)
Kidney or liver problems
Back pain, arthritis, or joint disorders
Anxiety, depression, or other mental health conditions
None of these
Do you smoke or use tobacco products?
Yes
No
Do you consume alcohol?
Yes, regularly
Occasionally
No
Do you engage in any high-risk activities or sports (e.g., skydiving, scuba diving)?
Yes
No
Are you planning to enroll in the next 3 months?
Yes
No
Are you currently working and have employer coverage?
Yes
No
What are you looking for in your Medicare plan? (Check all that apply)
Lower monthly premiums
Freedom to see any doctor/hospital (no network restrictions)
Prescription drug coverage (Part D)
Dental, vision, and hearing coverage
Out-of-pocket cost protection
Help with copays, coinsurance, and deductibles
Additional benefits (e.g., gym membership, transportation, OTC)
Do you have any chronic conditions?
Yes
No
Please list
Do you receive Medicaid or any state assistance?
Yes
No
Do you currently have:
Medicare Advantage (Part C)
Medicare Supplement (Medigap)
Prescription Drug Plan (Part D)
Employer/Union/Retiree Health Plan
TRICARE or VA Benefits
None
Submit
Contact Me
Full Name
Phone Number
Email
Message
SUBMIT
