Virtual Appointments | Indy Health Insurance Agent

Join Your Appointment

Click the button below to start your call with IndyHealthAgent – Larry. The meeting opens in a pop-up on desktop or a new tab on mobile.

Tip: Allow your browser to use your camera & microphone. If a pop-up is blocked, the meeting will open in a new tab.

Client Facing Application General

NAME OF APPLICANT

PLAN NAME(s) APPLYING FOR

What type of coverage?

ACA/MARKETPLACE

LIFE INSURANCE

MEDICARE ADVANTAGE

MEDICARE SUPPLEMENT

PDP - PART D MEDICARE

ANCILLARY - DENTAL, SUPPLEMENT, VISION, DISABILITY, ILLNESS, ACCIDENT, ET.

Primary Family Address:

Address Line 1

Address Line 2

City

State

Zip Code

Who is applying for coverage?

Please list the full names and dates of birth of everyone needing coverage.

Do you or anyone applying use tobacco? - Yes - No

What is your estimated household income for this year (INCLUDE A BREAKDOWN OF FROM WHERE AND HOW MUCH EACH SOURCE)?

Do you currently have insurance? LIST WHO AND COVERAGE TYPE

Do you have preferred Primary doctor?

In the past 5 years, have you (or other applicants) been diagnosed or treated for: Cancer, heart attack, stroke Liver/kidney disease COPD/emphysema/asthma Diabetes (type, insulin use, complications) Mental health/substance abuse treatment

In the last 12 months, have you (or other applicants) been hospitalized or had surgery (other than minor)? Do you have any pending medical tests or procedures? Product-Specific Accident coverage: Usually guaranteed issue (no health questions). Hospital indemnity: May ask about recent hospitalizations or pregnancy. Cancer/critical illness: Health history (cancer, heart/stroke, organ transplant).

Do you (or other covered applicants) have any major health conditions we should know about? LIST ANY HOSPITAL STAYS LAST 5 YEARS OR CHRONIC CONDITIONS IN LAST 10 YEARS-

Amount $ of coverage requested and term length (if applicable):

Please provide age, height, and weight of everyone applying:

What’s the main reason you want coverage?

Medicare ID Number

What are the start dates for your Medicare Part A and Part B?

Do you receive Medicaid or Extra Help (Low Income Subsidy)?

Yes

Beneficiary information (for life/disability benefits)

FAQs

Do I need to install anything?

No. Meetings run in your browser. For best results use Chrome or Edge.

Can we share documents?

Yes. We can screen share. You can also download any files above.

What if the video doesn’t load?

Click “Open Meeting in New Tab”, or refresh this page and allow camera/mic permissions.

Is my information secure?

We use encrypted transport and only collect what’s needed to assist you. See our Privacy Policy for details.

Questions? Call or text me at 1-317-482-7063

Join Your Appointment

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