Medicare For The Lazy Man - Supplement Questionnaire

Medicare Supplement Questionnaire Full

NAME (to appear on a legal contract)

(*)

* Missing or Invalid *

(*)

* Missing or Invalid *

Residence address:

* Missing or Invalid *

Invalid Input

* Missing or Invalid *

Mailing address (if different):

Invalid Input

Sex:

* Missing or Invalid *

Height:

Invalid Input

Phone:

* Missing or Invalid *

Birthdate:

Invalid Input

Weight:

Invalid Input

Business:

* Missing or Invalid *

Age:

* Missing or Invalid *

Smoke:

Yes

No

* Missing or Invalid *

Mobile:

* Missing or Invalid *

Text:

Yes

No

* Missing or Invalid *

Preferred contact method:

E-mail

Phone

Mail

* Missing or Invalid *

E-mail:(*)

* Missing or Invalid *

Application Verification Call - Preferred time of day?

Preferred time:

8 AM - Noon

Noon - 6 PM

6 PM - 9 PM

* Missing or Invalid *

Best phone number:

* Missing or Invalid *

Enrolled in Medicare? (if yes):

Medicare ID:

* Missing or Invalid *

Part A date:

Invalid Input

Part B date:

Invalid Input

Are you covered for assistance through the state Medicaid program?

Yes

No

* Missing or Invalid *

MEDICARE SUPPLEMENT PLAN(S)

AVAILABLE IF BORN 1954 OR EARLIER

Plan F

Plan F - High Deductible

Invalid Input

AVAILABLE TO ALL

Plan G

Plan G - High Deductible

Invalid Input

Desired effective date:

* Missing or Invalid *

PREMIUM PAYMENTS

Type:

Bank draft

Bill by mail

* Missing or Invalid *

Payment Frequency:

Monthly

Quarterly

Semi-Annual

Annual

Invalid Input

Preferred day of bank draft:

Invalid Input

* Missing or Invalid *

(Bank draft payments are required in most states. If bill by mail is marked, we will give priority to this choice where possible.)

INSURANCE COVERAGE - During the prior 63 days?

Start date:

Invalid Input

(anticipated)
End date:

Invalid Input

Reason for termination:

Invalid Input

Tell me all about your situation

Invalid Input

Questions?

Invalid Input

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Medicare Supplement Questionnaire Full

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