Intake

Client intake

Same sections as the KR Insurance intake: contact, who needs coverage, health, medications, current plan, and notes. Sample contacts stay in this browser. Submit does not leave this page.

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Sample contacts

Contact and address

First name, last name, phone, and email are required to save the sample. Time zone fills in from the ZIP.

Name and contact

First Name*

Last Name*

Telephone Number*

Email Address*

Address

Street Address

Street Address Line 2

City

State

ZIP Code

Time zone: Set from ZIP

Who needs coverage and health profiles

Select Applicant, Spouse, or Children to include them and edit that person's health profile. Use + to add another child.

Date of Birth*

Height and weight

Maternity coverage?

Dental and vision?

Tobacco use?

GLP-1 treatment, current or planned?

Mental health coverage?

Surgeries or hospitalizations in the past 2 years?

Major health conditions?

Medications

Health conditions

Current insurance details

Carrier

Plan

Cost

Deductible

Met deductible?

Preferred doctors

Notes

By saving this sample, you can see how an intake is reviewed. It is not shared with an agent or a carrier.

Sample only. Nothing is submitted outside this browser.