| Your Information: |
Your Name:*
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Address:
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City/State/Zip Code:*
What county do you live in?
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Phone:
Fax:
Email:*
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| Do you have Medicare Supplement Insurance now? Plan and Coverage Desired: |
Do you have Medicare Supplement Insurance now? Yes No
Who is your current Med. Sup. insurance company:
Which Supplement Plan would you prefer:
I need a quote to Cover:
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| Date of birth and sex of those to be insured: |
Your Date of Birth:
Your Sex:
Male Female
Spouse's Date of Birth:
Spouse's Sex:
Male Female
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| Health History: |
| If the answer to any of the following questions is "YES", you are not eligible for coverage unless you are applying from certain Blue Cross Plans that are not Medicare Supplements or your are 65 or older and applying within six (6) months of your enrollment in Medicare Part B. You must already be enrolled in Medicare Parts A and B to apply for these plans.
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A. Are you currently confined, or has confinement been recommended, to a bed, hospital, nursing facility, or other care facility, or do you need the assistance of a wheelchair?
Yes No
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B. Within the past 2 years have you been advised to have kidney dialysis, joint replacement or surgery for the heart, arteries or intestines which has not yet been done?
Yes No
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C. Within the past 2 years, have you been hospitalized 2 or more times, or been confined to a nursing home for 2 weeks? (Total all confinements.)
Yes No
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D. Within the past 2 years, have your ever experienced, been told you had, consulted for treatment, sought treatment, had treatment recommended, received treatment (including drug therapy) or been hospitalized for: internal cancer, leukemia, Hodgkin's disease, coronary artery disease, heart attack, nephritis, kidney failure, stroke, or brain disorder?
Yes No
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E. Within the past 5 years, have your ever experienced, been told you had, consulted for treatment, sought treatment. had treatment recommended, received treatment (including drug therapy) or been hospitalized for: AIDS/ARC, Alzheimer's disease, senility, dementia, parkinson's disease, Multiple Sclerosis, neuromuscular disorders, congestive heart failure, heart valve replacement, open heart surgery or angioplasty, organ transplant (except cornea), cirrhosis of the liver or complications of diabetes such as amputation or loss of sight?
Yes No
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This
page is provided as a service to you. It is not possible to bind any new
coverage from this request. If you have NOT received your confirmation
from us within 24 hours the same or next business day, please contact
us. NO COVERAGE IS CONSIDERED BOUND UNTIL YOU RECEIVE OUR CONFIRMATION.
Thank you for your understanding.
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