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Security Question # 1
What is your mother’s maiden name?
What was the name of your first pet?
What was the name of your first grade teacher?
What is your mother-in-law’s maiden name?
What was the name of your elementary/primary school?
What was your high school mascot?
What is your father’s middle name?
What was your home phone number growing up?
Answer
Security Question # 2
What is your mother’s maiden name?
What was the name of your first pet?
What was the name of your first grade teacher?
What is your mother-in-law’s maiden name?
What was the name of your elementary/primary school?
What was your high school mascot?
What is your father’s middle name?
What was your home phone number growing up?
Answer
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Let's continue with the basics:
First Name
Middle Initial
Last Name
Do you have a Medicare Advantage (Medicare Part C) plan?
Yes
No
Date of Birth
Gender: How do you identify?
Man
Non-binary
Woman
Prefer to self describe below
Self-describe
Email Address
Confirm Email
Phone Number
Phone Type
Mobile
Other
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Single
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Other
Employment Status
Full Time
Part Time
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Race
American Indian or Alaskan Native
Asian
Black or African-American
Hispanic or Latino
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I Would Rather Not Say
Have you ever served in the US military.
Yes
No
Preferred Language
English
Spanish
Household Size
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16 or more
Are you:
A Home Owner
A Renter
A Renter In An Assisted Living/Nursing Home
Living with Friends/Family
Homeless
Total Number of Income Earners in Household
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16 or more
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Preferred Method of Communication
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