Clover's Group

Insurance, Documents and Expenses

Faith · Hope · Love · God's Grace

Last updated: ____________

Condensed Guide

Insurance, Documents and Expenses

Coverage, where every paper lives, and a monthly expense tracker.

3 pages · ~20 min · Prints on ≤ 3 Letter pages

CLOVER’S GROUP

Faith · Hope · Love · God’s Grace

Do not enter Social Security numbers, passwords, banking or full account numbers here. Store this printout in a safe place.

Insurance & benefits

page 1 / 3

Medicare

Plan name

Member ID (last 4 only)

Phone

Portal / website

Effective date

Renewal date

Notes / authorization details

Medicaid

Plan name

Member ID (last 4 only)

Phone

Caseworker

Effective date

Renewal date

Notes / authorization details

Private / employer + LTC + VA + Rx + Other

Plan name

Member ID (last 4 only)

Group number

Phone

Carrier

Policy #

Phone

Benefits + waiting period + claim notes

VA benefit type (aid & attendance, health, etc.)

VA contact

Phone

Prescription plan

Phone

Other assistance (foundations, discount programs)

Where the paper copies are kept

Important documents locator

page 2 / 3

Documents

Document 1

Document (ID, insurance card, advance directive, DPOA, living will, will/trust, guardianship, marriage cert, military records, insurance policies, property info, burial wishes, key contacts, etc.)

Location

Primary holder

Date of document

Notes

Monthly expense tracker (refill)

page 3 / 3

Month

Month + year

Expenses

Expense 1

Date

Vendor

Monthly totals

Monthly total

Reimbursable total