EmailMe Form - Medicare Supplement Application Questions

EmailMeForm

First & Last Name: *
First Last
Middle Initial:
Main Phone: *
### - ### - ####
Email
Resident Address: *

Street Address City State / Province / Region Postal / Zip Code Country / Region
Date of Birth: *
MM / DD / YYYY
Have you used ANY FORM of tobacco within the last 12 months? *
No
Yes
Height *
Weight: *
Enter a 2 or 3 digit number only for your weight. e.g. "175"
State of Birth: *
Insurance Coverage Questions Section
Please complete the details below.
Desired Insurance Company: *
Desired Insurance Policy: *
Requested Effective Date: *
MM / DD / YYYY
Your choice to this answer is only a recommendation for us. We can NOT guarantee any policy effective dates.
Quoted Premium (if any):
$ Dollars . Cents
If we quoted you a price, enter it above.
Preferred Payment Method: *
Preferred Payment Mode: *
Monthly payment is not available if you are paying by direct bill.
Preferred Bank Withdrawal Date:
Complete if you are paying by automatic bank withdrawal. AARP requires the 5th.
Medicare Part A (Hospital) Effective Date:
MM / DD / YYYY
This is shown on your red, white, and blue Medicare card.
Medicare Part B (Medical) Effective Date:
MM / DD / YYYY
This is shown on your red, white, and blue Medicare card.
Do you currently have a Medicare Supplement Policy? *
No
Yes
Have you had a Medicare Advantage Plan (aka Medicare Part C or Medicare Replacement) Policy within the past 63 days? *
No
Yes
Not Sure
Have you had coverage under any other health insurance within the past 63 days (Non-Medicare)? *
No
Yes
Not Sure
Example: An employer group health insurance policy, individual policy, non-Medicare retiree plan.
Current Insurance Company:
Current Premium:
$ Dollars . Cents
Current Medigap Policy:
Select an option only if you currently have a Medicare Supplement (Medigap) Plan.
Do you receive assistance through the state MEDICAID program (low income)? *
No
Yes
Not Sure
Did you enroll in Medicare Part B within the last 6 moths? *
No
Yes
Not Sure
Your Medicare Part B start date will be listed on your red, white, and blue Medicare card.
Did you turn age 65 within the last 6 months? *
No
Yes
Please list any health problems, medical conditions, hospitalizations, or heart problems you have had within the past 5 years, and an estimated date of occurrence:
Prescription & Over-the-Counter Medications Section
Please enter the details below for any prescription or over-the-counter medications that you are currently taking or have taken over the past 12 months. This does not include general vitamins. If you are just getting Medicare Part B, or know that you are guaranteed coverage, you can leave this section blank.
How many prescription medications do you currently take? *
MEDICATION #1
Medication Name:
Copy from medication label.
Date Originally Prescribed:
Estimated date when you started the medication.
Frequency & Dosage:
Example: 1 x Daily - 25mg
Diagnosis / Condition:
Example: High Blood Pressure
MEDICATION #2
Medication Name:
Copy from medication label.
Date Originally Prescribed:
Estimated date when you started the medication.
Frequency & Dosage:
Example: 1 x Daily - 25mg
Diagnosis / Condition:
Example: High Blood Pressure
MEDICATION #3
Medication Name:
Copy from medication label.
Date Originally Prescribed:
Estimated date when you started the medication.
Frequency & Dosage:
Example: 1 x Daily - 25mg
Diagnosis / Condition:
Example: High Blood Pressure
MEDICATION #4
Medication Name:
Copy from medication label.
Date Originally Prescribed:
Estimated date when you started the medication.
Frequency & Dosage:
Example: 1 x Daily - 25mg
Diagnosis / Condition:
Example: High Blood Pressure
MEDICATION #5
Medication Name:
Copy from medication label.
Date Originally Prescribed:
Estimated date when you started the medication.
Frequency & Dosage:
Example: 1 x Daily - 25mg
Diagnosis / Condition:
Example: High Blood Pressure
MEDICATION #6
Medication Name:
Copy from medication label.
Date Originally Prescribed:
Estimated date when you started the medication.
Frequency & Dosage:
Example: 1 x Daily - 25mg
Diagnosis / Condition:
Example: High Blood Pressure
MEDICATION #7
Medication Name:
Copy from medication label.
Date Originally Prescribed:
Estimated date when you started the medication.
Frequency & Dosage:
Example: 1 x Daily - 25mg
Diagnosis / Condition:
Example: High Blood Pressure
MEDICATION #8
Medication Name:
Copy from medication label.
Date Originally Prescribed:
Estimated date when you started the medication.
Frequency & Dosage:
Example: 1 x Daily - 25mg
Diagnosis / Condition:
Example: High Blood Pressure
MEDICATION #9
Medication Name:
Copy from medication label.
Date Originally Prescribed:
Estimated date when you started the medication.
Frequency & Dosage:
Example: 1 x Daily - 25mg
Diagnosis / Condition:
Example: High Blood Pressure
MEDICATION #10
Medication Name:
Copy from medication label.
Date Originally Prescribed:
Estimated date when you started the medication.
Frequency & Dosage:
Example: 1 x Daily - 25mg
Diagnosis / Condition:
Example: High Blood Pressure
Please complete this survey. *

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Note: After you submit this form, we will transfer this information to the application for the insurance company that you have chosen to apply for. We will need to call you to verify that you are ready to submit your application, and gather any other required details necessary before your application is submitted. Completing this form does not accept or guarantee your coverage. Please call us immediately at (800) 351-6603 if you have any questions.

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Insurance Coverage Questions Section

Prescription & Over-the-Counter Medications Section

MEDICATION #1

MEDICATION #2

MEDICATION #3

MEDICATION #4

MEDICATION #5

MEDICATION #6

MEDICATION #7

MEDICATION #8

MEDICATION #9

MEDICATION #10