Fill out this form in order to receive a
Medicare supplemental insurance
coverage quote. We forward your
information to a licensed Medicare
supplemental insurance agent in
your area who will contact you in a
timely manner, usually within a few
hours, with a quote(s) by the method
you request: email or phone
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and we provide your personal
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We also require that insurance
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Applicant: Full Name:   
Home Address:
City:   State:   Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
Date of Birth:  (mm/dd/yyyy)  Contact me:
Are you a U.S. citizen?
Do you have an Alien Registration Receipt Card?
Card Number:
U.S. Arrival Date:  (mm/dd/yyyy)


Are you covered under Medicare "Part A"?
If "No", when will you become eligible?  (mm/dd/yyyy)

Are you covered under Medicare "Part B"?
If "No", when will you become eligible?  (mm/dd/yyyy)

Are you covered for medical assistance through the state Medicaid program?
...as a specified low income Medicare beneficiary?
...as a qualified Medicare beneficiary?
...for other Medicaid medical benefits?

Do you have another Medicare supplemental insurance
policy or certificate in force?
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/yy)



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?

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?

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?


Do you have Parkinson's Disease or Multiple or Lateral Sclerosis?

Are you currently hospitalized or confined to a nursing facility, or are you bedridden or
confined to a wheelchair?

Have you been diagnosed with Alzheimer's Disease, senile dementia, organic brain disorder,
or any other senility disorder?

Do you have kidney disease requiring dialysis or diabetes requiring more than 50 units
of insuline daily?

Do you have emphysema, Chronic Obstructive Pulmonary Disease (COPD), or other
Chronic Pulmonary disorders?

Have you been advised to have surgery or medical tests that have not been performed?

Have you used tobacco in any form during the last 12 months?

Are you currently taking or have you taken any prescription or over-the-counter
medications during the last 12 months?

If you answered "Yes" to the question above please provide the necessary information below:

Medication Name:   Dosage: Frequency:
Reason/Condition:

Medication Name:   Dosage: Frequency:
Reason/Condition:

Medication Name:   Dosage: Frequency:
Reason/Condition:

                                         Is Spouse to be insured?
Spouse: Full Name:   
Spouse Date of Birth:  (mm/dd/yyyy)
Spouse Gender:
Is spouse a U.S. citizen?
Does spouse have an Alien Registration Receipt Card?
Card Number:
Spouse's U.S. Arrival Date:  (mm/dd/yyyy)


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

Is spouse covered under Medicare "Part B"?
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?
...as a qualified Medicare beneficiary?
...for other Medicaid medical benefits?

Does spouse have another Medicare supplemental insurance policy or certificate in force?
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)


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?

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?

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?


Does spouse have Parkinson's Disease or Multiple or Lateral Sclerosis?

Is spouse currently hospitalized or confined to a nursing facility, or bedridden or
confined to a wheelchair?

Has spouse been diagnosed with Alzheimer's Disease, senile dementia, organic brain disorder,
or any other senility disorder?

Does spouse have kidney disease requiring dialysis or diabetes requiring more than 50 units
of insuline daily?

Does spouse have emphysema, Chronic Obstructive Pulmonary Disease (COPD), or other
Chronic Pulmonary disorders?

Has spouse been advised to have surgery or medical tests that have not been performed?

Has spouse used tobacco in any form during the last 12 months?

Is spouse currently taking or has taken any prescription or over-the-counter
medications during the last 12 months?

If the answer was "Yes" to the question above please provide the necessary information below:

Medication Name:   Dosage: Frequency:
Reason/Condition:

Medication Name:   Dosage: Frequency:
Reason/Condition:

Medication Name:   Dosage: Frequency:
Reason/Condition:

Additional Information or Comments



Click on the "Submit Quote Information" button below to send
your Medicare supplemental insurance quote request.


Applicant Information
Current Medicare Information
Health Questions for Medicare Supplemental Insurance Quote
Spouse Information
Current Medicare Information
Spouse Health Questions for Medicare Supplemental Insurance Quote
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Medicare Supplemental Insurance
Medicare Supplemental Insurance Quote
Information received from this Medicare supplemental insurance quote form sent to Insured Insurance Service.com will be forwarded to
insurance agents licensed to sell Medicare supplemental insurance coverages in your state. Insured Insurance Service.com is not a licensed
insurance agent and in no way intends to represent itself as such. Quotes will be created by insurance agents based on the information you
provide and Insured Insurance Service.com is not affiliated with, partnered, or owned by any of the insurance agencies that will provide quotes.
The precise coverage afforded is subject to meeting underwriting guidelines, and the terms, conditions and exclusions of the policy as issued.
By submitting this request you acknowledge that this is neither an offer to insure nor a guarantee of insurance. Completion of this form does not
entitle you to Medicare supplementall insurance.
Medicare supplemental insurance
quotes are available if you reside
in one of the states listed below:
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