Client fit form

A health care form for your clients.

This form gives agency clients an estimate of how group-rate health care could affect their health care costs and taxable income. It screens their answers against initial-fit baselines and, when appropriate, invites them to schedule time with the broker.

Starting point

Start with two baseline numbers.

The initial screen starts with both baselines.

2026 net business income: $80,000 or more
Current health care spending: About $700 per month or more

A client below either baseline is generally outside the program’s initial fit range. Meeting both means only that closer review may be appropriate. The form does not provide a quote or determine pricing, savings, coverage, eligibility, or provider acceptance.

Client-facing form

This is the form they would use.

You can embed it on your site or send clients here.