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Medicare Supplement
Quote

Part I - Applicant Information
Proposed Insured
Name:
Social Security #:
Birthdate:
Medicare #:
Height & Weight:
Gender:
 Male Female
Have you used tobacco within the last 12 months?
 Yes No
Spouse
Name:
Social Security #:
Birthdate:
Medicare #:
Height & Weight:
Gender:
 Male Female
Have you used tobacco within the last 12 months?
 Yes No
Applicant Address:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Fax:
Email:

Part II - Medical & General Questions
Please give details to "Yes" answers in space provided.
A. Do you have another (or pending applications for) Medicare Supplement policy or certificate in force?
 No Yes
Include insured or spouse name.
2. If so, do you intend to replace your current Medicare Supplement policy with this policy?
 No Yes
B. Do you have any other health insurance coverage that provides benefits similar to this Medicare Supplement Policy?
 No Yes
If so, with which company?
What kind of policy?
C. Are you covered for medical assistance through the state Medicaid program?
1. As a Specified Low-Income Medicare Beneficiary (SLMB)
 No Yes
2. As a Qualified Medicare Beneficiary (QMB)?
 No Yes
3. For other Medicaid medical benefits?
 No Yes
D. Are you covered or will you be covered under:
Medicare Part A (Hospitalization)
 No Yes
Effective Date Insured:
Effective Date Spouse:
Medicare Part B (Medical Expenses)
 No Yes
Effective Date Insured:
Effective Date Spouse:

Health Questions (Answer for all Insureds)
Questions 1-6 are not required of applicants applying for this coverage within 6 months of obtaining Medicare Part B, or under guaranteed issue status.

1. Within the past two years have you had, or had a medical diagnosis of:
Are you taking medication?
 No Yes
Do you have high blood pressure?
 No Yes
Do you have asthma, emphysema or respiratory problems?
 No Yes
Do you have cancer or other tumors?
 No Yes
Do you have diabetes?
 No Yes
Do you have AIDS; HIV?
 No Yes
Are you pregnant?
 No Yes
Have you ever been declined life, health or disability insurance?
 No Yes
Are you a U.S. citizen?
 No Yes
Remarks
Coverage Information
Your annual gross salary, including tips, fees, and commissions:
How long have you been employed at your present occupation?
What percentage of your income do you want your disability policy to cover?
 50% 60% 65% 70%
How long do you want the elimination period to be (the length of time you must be disabled before you start to receive benefits)?
 30 days 60 days 90 days 6 months 1 year 2 years
How long do you want the benefit period to be (the maximum length of time you will receive benefits after you have been classified as being disabled and satisfied the elimination period)?
 2 years 3 years 4 years 5 years Until age 65
Are you self-employed?
 No Yes
What is your occupation?
Please describe briefly your duties at your current job.
Is there a particular reason why you are purchasing disability insurance?
 No Yes
If yes, please explain.
Do you have disability insurance?
 No Yes
If yes, how much do you have?
Questions or comments
When is the best time to call and discuss your quote?
 Morning Afternoon Evening Anytime Other
If other, please specify:

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