Medicare Supplements Request for Quote

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REQUEST FOR QUOTE APPLICATION
(APPLICANT FORM)

To receive a no obligation quote for Medicare Supplemental Insurance, please fill in the form below and press SUBMIT.

If you prefer, you may print a copy of the application, fill it out and fax to our toll-free fax at 1-866-541-3535. Acrobat Reader is required for this option (get it free here!)

THIS FORM IS FOR THE APPLICANT. IF COVERAGE IS REQUIRED FOR A SPOUSE THEN A SPOUSE APPLICATION
MUST ALSO BE SUBMITTED. CLICK HERE FOR THE SPOUSE APPLICATION

Red Indicates a Required Field
Applicant Form

Applicant Name:
Street Address:
City:
State:
Zip:
Phone:
Fax:
E-Mail:
Sex:
Birth date:
Height:
Weight:
Have you used any form of tobacco in the past five years?
Are you covered under Medicare Part A?
Are you covered under Medicare Part B?

HEALTH QUESTIONS 1-9 ARE NOT REQUIRED OF AN APPLICANT APPLYING FOR THIS COVERAGE WITHIN 6 MONTHS OF APPLICANT'S 65th BIRTH MONTH

1.	Are you bedridden or confined to a wheelchair?
2.	Are you currently hospitalized or confined to a nursing facility; or have you been hospitalized two or more times within the past year?
3.	Within the past two years, have you been advised to have kidney dialysis?
4.	Within the past two years have you had a heart attack, stroke or heart valve surgery?
5.	Within the past two years, have you had or been treated for internal cancer, leukemia or malignant melanoma, Hodgkin’s Disease, Parkinson’s Disease, disabling arthritis, degenerative bone disease, cirrhosis of the liver, Alzheimer’s Disease or alcohol or drug abuse?
6.	Within the past two years, have you been advised to have surgery for cataracts, joint replacement, a heart condition or other in-patient surgery but not had such surgery?
7.	Have you had or been told by your physician you have emphysema, chronic bronchitis, or Amyotrophic Lateral Sclerosis or paralysis?
8.	Have you ever tested positive for exposure to the HIV infection or been diagnosed as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection?
9.	Have you had or been told by your physician you needed amputation due to a disease?
10.	Are you an insulin dependent diabetic?

GOOD HEALTH DISCOUNTS. An adult may qualify for preferred discounts is (s)he has not used tobacco in the past 5 years. Preferred Class can save an extra 5% to 10% of premium.

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