Eligibility Assessment

At Clear Solutions, we want to empower you with a plan. This FREE Eligibility Assessment is a no obligation service that we provide. We will manually review your information and give you our best assessment of your eligibility. Once complete, your results will be provided over the phone or via email – whichever you prefer.

Note: The questions below are necessary to give you the best eligibility assessment possible. It is important to fill out the questionnaire completely. The questions are similar to the questions asked on an application for coverage. Any information will be kept confidential. The privacy laws apply to any information provided.

Name

Phone Number

Date of Birth

Gender

Height

Weight

Where Are You Located?

How Did You Hear About Us?

Do You Have A Spouse?

If you have a spouse, they need to complete the questionnaire after your submit your own

I understand

Are You Currently Taking Any Medication?

Yes No

If you answered "yes," list your medications here

Have You Been Hospitalized In The Last 5 Years?

Yes No

If you answered "yes," describe what you were hospitalized for

I'm Interested In: (check all options you are interested in)

Have You Used Tobacco In The Last Year?

Yes No

Are you currently using oxygen, a wheelchair, crutches or cane?

Yes No

Are you currently on disability?

Yes No

Do you have a surgery scheduled in the next six (6) months?

Yes No

Have you been declined for Any insurance in the past 12 months?

Yes No

Is there a history of any of the following conditions? We have to ask these questions to give you the best information possible. No insurance provider will issue a plan without verifying these facts first.

I understand

Abnormal Blood Pressure

Yes No

AIDS/ARC

Yes No

Alcohol Abuse

Yes No

ALS

Yes No

Alzheimer's Disease

Yes No

Amputation

Yes No

Anemia

Yes No

Aneurysm

Yes No

Arthritis

Yes No

Asthma

Yes No

Atrial Fibrillation

Yes No

Bipolar/Manic Depression

Yes No

Cancer

Yes No

Cardiomyopathy

Yes No

Carotid Artery Disease

Yes No

Cerebral Vascular Disease

Yes No

Congestive Heart Failure

Yes No

COPD/Emphysema

Yes No

Coronary Artery Disease

Yes No

Chrons Disease

Yes No

Dementia

Yes No

Depression/Anxiety

Yes No

Diabetes

Yes No

Dizziness/Vertigo

Yes No

Drug Abuse

Yes No

Eye Disease

Yes No

Heart Attack

Yes No

Hepatitis

Yes No

Hodgkins Disease

Yes No

Joint Replacement

Yes No

Kidney Failure

Yes No

Leukemia

Yes No

Lupus

Yes No

Lymphoma

Yes No

Memory Loss

Yes No

Multiple Sclerosis

Yes No

Muscular Dystrophy

Yes No

Myasthenia Gravis

Yes No

Neurogenic Bladder

Yes No

Neuropathy

Yes No

Organ Transplant

Yes No

Organic Brain Syndrome

Yes No

Osteoporosis

Yes No

Paralysis

Yes No

Parkinson's Disease

Yes No

Peripheral Vascular Disease

Yes No

Rheumatoid Arthritis

Yes No

Scleroderma

Yes No

Seizures

Yes No

Stroke or TIA

Yes No

Tremor

Yes No

How Would You Like To Receive Your Results?

Phone Email

After you hit submit, you will be directed to a page that will have a link to come back to the form and add other applicants.

IMPORTANT: After receiving your information please allow us 2 days to get back to you with your results.

After your assessment has been delivered, you will have the opportunity to continue utilizing our resource services if you desire. We will give you more information on this in the follow up email.

Clear Solutions Insurance Services is here to educate and empower you with income protection planning, providing you with the proper confidence, knowledge, and tools to help protect your greatest asset: you.

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You also get access to our FREE online eligibility assessment tool and direct access to Tom to answer your questions and help with coaching if you desire.

At Clear Solutions Insurance Services, we are 100% dedicated to protecting you online and providing a safe haven free from “being sold”. We will never share your information with anyone.

Eligibility Assessment

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