Medicare Supplements


MEDICARE SUBMISSION FORM
* denote what should be required fields.

* Type of Coverage Desired Medicare Supplement
Long Term Care
Estate Planning
Prescription Discounts
Annuity Updates
* Name
  Address:
  City
* State
* Zip
* Phone
  Fax
* E-mail
* Desired Coverage Effective Date
INDIVIDUALS TO BE INSURED:
* Sex Male Female
* Age or Date Of Birth
  Height Feet Inches
  Weight
  Tobacco User Within Past Year Yes No
CURRENT INSURANCE INFORMATION:
  Existing Carrier
  Expiration Date
  Current Monthly Premium
SPOUSE INFORMATION:
  Spouse Sex Male Female
  Date Of Birth
  Height Feet Inches
  Weight
  Tobacco User Within Past Year Yes No
  Number of children
INSURANCE INFORMATION:
* Have any of the applicants
received medical attention
within the past 10 years for
any of the following:
Stroke, System Disorders,
Emphysema, Heart/Circulatory/
Liver/Kidney/Immune Rheumatoid
Arthritis, Ulcerative Colitis,
Diabetes, Cancer, Alcohol/Drug
Abuse, or HIV. 		Yes No