Forms

Select and Start Your Insurance Intake Form

Choose the application that matches your coverage needs. Mercy will review your details and follow up with plan options.

Insurance advisor ready to help

Under 65 Health Insurance Intake Form

Share household, income, plan, payment, and coverage details for Marketplace health insurance options.

Schema 2026-03-21

Start Form

Medicare Advantage Intake Application

Provide beneficiary, contact, primary care, enrollment, and plan preference details.

Schema 2026-03-21

Start Form

Medicare Supplement Intake Form

Send Medicare, plan choice, eligibility, agent, payment, and enrollment details.

Schema 2026-04-03

Start Form

Life Insurance Application

Complete personal, banking, employment, lifestyle, beneficiary, and coverage information.

Schema 2026-04-03

Start Form

What these forms are for

These intake forms collect the information needed to prepare a coverage comparison before a conversation, so that the first call can be about options rather than about data gathering. They are not applications. Submitting one does not enroll you in anything, does not bind coverage, and does not create an obligation on either side.

Enrollment always happens through the carrier or through the Marketplace, using their own application. What you provide here is used to prepare for that step and to work out which path applies to you in the first place.

Separate forms exist because the information that matters differs by product. An under-65 health comparison turns on household income, tax household composition, doctors, and prescriptions. A Medicare review turns on your 65th birthday, current employment, existing coverage, and whether you have already enrolled in Part A or Part B. A life insurance review turns on the obligation you are covering and your health history.

Accuracy matters more than completeness

A partially completed form with accurate figures is more useful than a fully completed one with guesses. The two entries that most often cause problems downstream are household income for the coverage year and tax household composition.

Income should be your realistic expected total for the coverage year, for everyone in your tax household — not last year's figure, and not just the applicant's. Tax household means the people you claim on your return, which can include a dependent who lives elsewhere and exclude a roommate who lives with you.

If your income is variable because you are self-employed, seasonal, or paid on commission, say so rather than picking a number to look tidy. A range with an explanation leads to better advice than a precise figure that turns out to be wrong.

How your information is handled

Information submitted through these forms is used to respond to your request and prepare a comparison. It is not sold to lead aggregators or marketing lists.

Providing a phone number constitutes consent to be contacted about your inquiry by phone, text, or email. Message and data rates may apply. You can withdraw that consent at any time by asking to be removed, and doing so does not affect servicing of an existing policy.

Health information you provide is used to check plan fit — networks, formularies, benefit design. ACA Marketplace coverage cannot be medically underwritten, so health history does not affect your eligibility or price there. Life insurance and short-term medical are medically underwritten by the carrier, and health information in those applications goes to the carrier as part of underwriting.

Do not send a Social Security number, a full date of birth for identity purposes, or financial account details through a web form. Those are collected through the carrier or Marketplace application directly, in their own secure systems.

What happens to a form after you send it

A submitted form is reviewed to work out which coverage path applies before any plan is discussed. That determination — employer coverage, Marketplace, Medicare, or a public program — comes first because it shapes everything after it.

If the form suggests you may be eligible for Medicaid or CHIP, that is where the conversation goes, and those are not brokered products. Eligibility is determined by your state agency, and applying is free and available year-round with no enrollment window.

If a Marketplace plan is the path, the next step is checking whether an enrollment window is open for you. Outside Open Enrollment that means identifying a qualifying life event, and since most of those windows run 60 days from the event, timing is often the first constraint rather than the last.

Where a comparison is prepared, it covers plans from represented carriers checked against the doctors, prescriptions, and expected care you listed. It is not a complete picture of every plan available in your county — the official Marketplace preview shows that — and any comparison should be read alongside it.

Nothing submitted through a form enrolls you or binds coverage. Enrollment happens through the carrier or the Marketplace, on their own application, and coverage generally begins only once the first premium is paid.

Which form applies to your situation

The forms are separated by product because the information that determines a good recommendation is genuinely different for each. Filling in the wrong one is not a problem — it simply means a follow-up for the details the right one would have captured.

  • Under-65 health coverage: for individuals and families who need major medical coverage and are not yet Medicare-eligible. Turns on household income, tax household composition, doctors, and prescriptions.
  • Medicare: for anyone approaching 65, already on Medicare, or Medicare-eligible through disability. Turns on your 65th birthday, current employment, existing coverage, and whether you have already enrolled in Part A or Part B.
  • Medicare Advantage: for people comparing Advantage plans specifically, where network and formulary detail matters more than in a general review.
  • Medicare Supplement: for people considering Medigap, where the timing of your six-month open enrollment window is the first thing to establish.
  • Life insurance: turns on the obligation you are covering, its duration, and your health history, since life insurance is medically underwritten.

If you are not sure a form is the right starting point

A form is the efficient path when you already know roughly what you need. If you do not, a short conversation first is usually faster than filling in a form for the wrong product and correcting it afterward.

Situations where a call tends to beat a form: you are not sure whether Medicare or Marketplace coverage applies to you, you have household members in different situations, you have just had a life event and are not sure what it opens, or you are dealing with a problem on existing coverage rather than shopping for new coverage.

You are also not obligated to use a form at all. Enrollment in Marketplace and Medicare coverage is available directly through the official sites at no cost, and if your situation is straightforward that may be the most direct route. A form here exists to make a comparison conversation more productive, not to insert a step you do not need.

After you submit: what to expect and when

You should receive an acknowledgement that the form arrived, and a substantive response generally within one business day. During Open Enrollment and the weeks around it, volume is much higher and a response can take longer — which is the practical argument for starting well before a deadline rather than in its final week.

The first response is usually a clarifying question rather than a plan recommendation, because the details that determine a good recommendation are rarely all present on a form. Expect to be asked about anything ambiguous in your income estimate, household composition, or existing coverage before any options are presented.

If your situation turns out to fall outside the states where the appropriate license is held, or outside the products represented, you will be told that directly and pointed toward the right resource. That is a faster outcome than a conversation that cannot end in coverage.

Where a comparison is prepared, expect it to name the trade-offs rather than present a single recommendation. Two plans that differ on network breadth, deductible, and formulary tier placement are rarely separable into better and worse without knowing which of those matters most to your household, and that judgement belongs to you rather than to the person preparing the comparison.

Nothing you submit obligates you to anything, and you can ask to be removed from contact at any time. Withdrawing consent for marketing contact does not affect servicing of a policy you already hold.