Medicare Health Plans Quote Request

Name

Birth Date

Medicare #

Age

Sex

Height

Weight

Have you used tobacco within the last 12 months?

Please provide the required field.

Address

Phone Number

Alternate Telephone

A. Do you have a (or pending applications for) Medicare Supplement policy or certificate in force?

Please provide the required field.

If yes, please describe

2. If so, do you intend to replace your current Medicare Supplement policy with this policy?

Please provide the required field.

If yes, please describe

B. Do you have any other health insurance coverage that provides Medicare benefits?

Please provide the required field.

If so, with which company?

What kind of policy?

1. As a Specified Low-Income Medicare Beneficiary (SLMB)

Please provide the required field.

2. As a Qualified Medicare Beneficiary (QMB)

Please provide the required field.

For other Medicaid medical benefits?

Please provide the required field.

Medicare Part A (Hospitalization)

Please provide the required field.

Effective Date Insured:

Effective Date Spouse:

Medicare Part B (Medical Expenses)

Please provide the required field.

Effective Date Insured:

Effective Date Spouse:

a. Cirrhosis; Hemophilia; Multiple Sclerosis; Leukemia; Amputations due to Diabetes?

Please provide the required field.

b. Renal Dialysis; Kidney Dialysis; X-Ray Therapy; Radium or Chemotherapy; Degenerative (Crippling) Arthritis; Internal Cancer; Stroke?

Please provide the required field.

c. Emphysema (under treatment); Hodgkins Disease; Disease or Disorder of Lungs or Respiratory Syustem which requires the outside assistance of a Mechanical Breathing Device?

Please provide the required field.

d. Heart attack; angina; transient ischemic attack (TIA); heart failure; heart surgery; angioplasty or coronary by-pass surgery?

Please provide the required field.

e. Parkinson's disease; Alzheimer's disease; senile dementia; organic brain disease or other senility disorders?

Please provide the required field.

2. Are you an insulin dependent diabetic taking more than 50 units per day?

Please provide the required field.

3. Have you been confined to a nursing home or a wheelchair within the past two years or has such care been medically advised?

Please provide the required field.

4. Are you currently hospitalized, or receiving Medicare approved home health care; or have you been hospitalized or received Medicare approved home health care three or more times in the past two years?

Please provide the required field.

5. Within the past year have you been medically advised to have surgery but not had such surgery?

Please provide the required field.

6. Within the past 5 years, have you been medically diagnosed by a member of the medical profession as having any disease or disorder of the immune system, AIDS Related Complex (ARC), or have you tested positive for the HIV infection?

Please provide the required field.
Please provide the required field.

Enter both words below, separated by a space

Please enter the words or numbers you hear

Can't read the words below? Try different words or an audio captcha

This is a standard security test that we use to prevent spammers from submitting fake response More Help

This web site may contain concepts that have legal, accounting and tax implications. It is not intended to provide legal, accounting or tax advice. You may wish to consult a competent attorney, tax advisor, or accountant.