Medicare Supplement Quote Request
Name *
Address *
City * State* Zip *
Home Phone * Business Phone
Fax    Cell Phone 
E-mail Address *
Best time to contact you: Daytime Evening
Are you eligible ( or will be within 6 months ) for Medicare?
Do you plan to purchase coverage during your 6 month
Open Enrollment Period? Yes No
Please enter your Age:
Requested effective date (must be within 90 days)* / / (MM/DD/YYYY)
Are you replacing current or recent coverage? Yes No
If yes, please answer the following questions:
Name of health carrier:
Type of plan:
Termination date: / / (MM/DD/YYYY)
*do not cancel any existing health coverage until you are notified in writing of your acceptance into a Medicare Supplement Plan.
Health Questions
You do not need to complete these health questions if you are applying for Plan A or for guaranteed-issue Plan C or if you are applying during the six-month open enrollment period which begins the month you first became both 65 or older and were enrolled in Medicare Part B.
1. Within the last two years, have you received medical advice or prescription drugs for liver problems, internal cancer, stroke, Amyotrophic Lateral Sclerosis (ALS), Multiple Sclerosis (MS); or within the last two years have you had heart or bypass surgery or angioplasty? Yes No
2. Have you received medical treatment or prescription drugs for Acquired Immune Deficiency Syndrome (AIDS) or AIDS-Related Complex (ARC) and/or tested HIV positive? Yes No
3. Do you currently use an oxygen device or require dialysis for kidney disease? Yes No
4. In the last twelve months, has the cost of all your current prescription medication exceeded $600? Yes No
NOTE: The following statements are true if you are not applying during the six-month open enrollment period:
  • If you answer "YES" to questions 1,2,or 3, you are only eligible to apply for Plan A or guaranteed-issue Plan C.
  • If you answer "YES" to questions 1,2,3,or 4, you do not qualify for Plan J.
Select Plan - click on the button of the plan that best meets your needs.
Medicare Supplement Plans
Service
PLAN
A
PLAN
C
PLAN
E
PLAN
F
PLAN
J
Part A Deductible # * * * *
Part A Coinsurance Days 61-150 * * * * *
365 Additional Hospital Days * * * * *
Part B 20% Coinsurance * * * * *
First 3 Pints of Blood * * * * *
Skilled Nursing
Coinsurance Days 21-100		 # * * * *
Part B Deductible # * # * *
Part B Excess at 100% # # # * *
Foreign Travel Emergency # * * * *
At-Home Recovery # # # # *
Extended Drugs ($3,000 Limit) # # # # *
Preventive Care # # * # *

This is a request for quotation only. No coverage is in effect until bound by an insurance carrier. A licensed agent will respond to your submission as soon as possible.