* =Required Fields

Full Name
Home Address
City
State
Zip
* Email
Home Phone
Work Phone
How to Contact You
Date of Birth
(mm/dd/yyyy)
Gender Male Female
  Height ft
Weight

Do you smoke? Yes No
Are you a U.S. citizen? Yes No

Current Medicare Information

Are you covered under Medicare "Part A"? Yes No
If "No", when will you become eligible?
(mm/dd/yyyy)
Are you covered under Medicare "Part B"? Yes No
If "No", when will you become eligible?
(mm/dd/yyyy)
Would you like a Medicare Advantage Plan Quote? Yes No
Are you covered for medical assistance through the state Medicaid program?
...as a specified low income Medicare beneficiary? Yes No
...as a qualified Medicare beneficiary? Yes No
...for other Medicaid medical benefits? Yes No
Do you have another Medicare supplement insurance policy or certificate in force? Yes No
If "Yes", do you intend to replace the current policy or certificate with this policy(certificate), and if so, what is the termination date?
(mm/dd/yyyy)

Questions for Illinois Medicare Supplement Insurance Quote

Within the last 2 years have you been aware of, diagnosed and /or been treated by a member of the medical profession for: heart disease or disorder, stroke, cancer, drug or alcohol dependency, mental disorder, crohn's disease or ulcerative colitis, nervous system disorder, liver disorder, spinal disc disease, knee or hip disorders, or any amputation caused by disease? Yes No
   
Have you been hospitalized within the past 12 months, due to be so confined or been disabled for more than 5 days within the past 12 months? Yes No
   
During the last 5 years have you been diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS related complex (ARC) or tested positive for HIV? Yes No
   
Do you have Parkinson's Disease or Multiple or Lateral Sclerosis? Yes No
   
Are you currently hospitalized or confined to a nursing facility, or are you bedridden or confined to a wheelchair? Yes No
   
Have you been diagnosed with Alzheimer's Disease, senile dementia, organic brain disorder, or any other senility disorder? Yes No
   
Do you have kidney disease requiring dialysis or diabetes requiring more than 50 units of insuline daily? Yes No
   
Do you have emphysema, Chronic Obstructive Pulmonary Disease (COPD), or other Chronic Pulmonary disorders? Yes No
   
Have you been advised to have surgery or medical tests that have not been performed? Yes No
   
Have you used tobacco in any form during the last 12 months? Yes No
   
Are you currently taking or have you taken any prescription or over-the-counter medications during the last 12 months? Yes No
   
If you answered "Yes" to the question above please provide the necessary information below:
Medication Name Dosage Frequency Condition

Spouse Information & Health Questions

Is Spouse to be insured? Yes No
Spouse Full Name:
Spouse Date of Birth
(mm/dd/yyyy)
Spouse Gender Male Female
Is spouse a U.S. citizen? Yes No

Spouse Current Medicare Information

Is spouse covered under Medicare "Part A"? Yes No
If "No", when will your spouse become eligible?
(mm/dd/yyyy)
Is spouse covered under Medicare "Part B"? Yes No
If "No", when will your spouse become eligible?
(mm/dd/yyyy)

Is spouse covered for medical assistance through the state Medicaid program?

...as a specified low income Medicare beneficiary? Yes No
...as a qualified Medicare beneficiary? Yes No
...for other Medicaid medical benefits? Yes No
Does spouse have another Medicare supplement insurance policy or certificate in force? Yes No
If "Yes", does spouse intend to replace the current policy or certificate with this policy(certificate), and if so, what is the termination date?
(mm/dd/yyyy)

Questions for Illinois Medicare Supplement Insurance Quote (Spouse)

Within the last 2 years has your spouse been aware of, diagnosed and /or been treated by a member of the medical profession for: heart disease or disorder, stroke, cancer, drug or alcohol dependency, mental disorder, crohn's disease or ulcerative colitis, nervous system disorder, liver disorder, spinal disc disease, knee or hip disorders, or any amputation caused by disease? Yes No
   
Has spouse been hospitalized within the past 12 months, due to be so confined or been disabled for more than 5 days within the past 12 months? Yes No
   
During the last 5 years has spouse been diagnosed by a member of the medical profession as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS related complex (ARC) or tested positive for HIV? Yes No
   
Does spouse have Parkinson's Disease or Multiple or Lateral Sclerosis? Yes No
   
Is Spouse currently hospitalized or confined to a nursing facility, or are you bedridden or confined to a wheelchair? Yes No
   
Has Spouse been diagnosed with Alzheimer's Disease, senile dementia, organic brain disorder, or any other senility disorder? Yes No
   
Do spouse have kidney disease requiring dialysis or diabetes requiring more than 50 units of insuline daily? Yes No
   
Do spouse have emphysema, Chronic Obstructive Pulmonary Disease (COPD), or other Chronic Pulmonary disorders? Yes No
   
Has spouse been advised to have surgery or medical tests that have not been performed? Yes No
   
Has spouse used tobacco in any form during the last 12 months? Yes No
   
Is spouse currently taking or taken any prescription or over-the-counter medications during the last 12 months? Yes No
   
If you answered "Yes" to the question above please provide the necessary information below:
Medication Name Dosage Frequency Condition

Additional Information or Comments

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