Home Medicare Supplement Plan Comparison Chart Before 06/01/2010 Medicare Supplement Plan Comparison Chart For 2013   Medicare Supplement Quote Request Contact Us
 
   

The Medicare Channel
(800) 728-9609

| More

 

Medicare Supplement Quote Request Form

Instructions: Complete the following form if you would like a Medicare Supplement quote and consultation. A Medicare Supplement & a MediGap plan are exactly the same thing.

I know, the form looks long but very little information is required to submit it. The form might take 1 to 2 minutes to complete. If you are uncomfortable with any of the information just leave it blank or call us now on the toll free number to the right.

Our Guarantee:

1) No Medicare supplement insurance agent will ever come to your home.

2) We guarantee to have the lowest prices for the Medicare Supplement plan you are interested in.

3) Only 1 agent will call you.

4) We do not collect your information and give it to anybody else for any reason. We actually sell the Medicare Supplement insurance policies.

5) All information provided on this form is confidential and will be used solely for the purpose of developing a Medicare supplement quote for you.

6) If you select us as your agent we promise to give you unlimited support when you are trying to select a Medicare Prescription Drug Plan (Part D). Many agents don't have the tools we have and are only interested in selling you the supplement and not helping you with your RX choice.

7) As an independent broker we have every major insurance company to quote from. We have already done the research and will quote you the lowest price from a company you know and trust.

Please understand this is not a Medicare supplement application. We will complete a Medicare supplement insurance application for you or help you easily complete the application yourself if coverage is desired

Call to speak to an agent 1-800-728-9609

What do you have to lose? We still like to provide good old fashioned customer service.

 

The only information required to submit this form is highlighted in yellow.

The rest of the information is optional but helps us help you select the right plan.

If you complete the required information and submit some but not all of the other information that's ok also.

 

Medicare Supplement Quote Request Form

Please rate yourself on how much you already know about Medicare Supplement insurance.

Do you know which plan you are interested in?                        
Part I - Primary Applicant & Contact Person looking for a Medicare Supplement Policy Quote:
Proposed Insured looking for a Medicare Supplement Insurance Quote *First Name
Middle Initial
*Last Name
*Date of Birth
*Age
*Sex
*Height 
*Weight
*Have you used tobacco within the last 12 months?  Yes  No
  Only Complete this section if You are interested in getting a Medicare Supplement quote for your Spouse.  
Spouse
First Name

Middle Initial
Last Name
Date of Birth
Age
Sex
Height
Weight
                          Has your Spouse used tobacco within the last 12 months?  Yes  No
Part II

*Applicant Contact information:
Street:
City:
Only the states we are licensed in are listed. *State:
*Zip:
*Phone #:
 
 
 
 
 
 
 
 
 
Please tell us the preferred contact phone number:
 *Home number or best contact number:
Cell:

Other:

HomeCell other
Email Address:
Part III - Medical & General Questions. All these questions below are not required to submit the Medicare Supplement quote request form but are helpful.
 
Basic Questions -
Please give details to "Yes" answers in space provided. Include insured or spouse name.
To The Best of Your Knowledge
A. Do you have Medicare Supplement Policy, Medicare Advantage Plan or other Medicare Supplement or MediGap Policy in force?		  Yes
 No
If Yes, which insurance company?
2. If yes, do you intend to replace your current Medicare Supplement Policy with this policy?  Yes
 No
B. Do you have any other health insurance coverage in force now? Like a group health insurance policy from your employer or an individual health insurance policy?  Yes
 No
If So, with which insurance company provides coverage?
What kind of policy?
C. Are you covered for medical assistance through the state Medicaid program? The next 3 questions will be No unless you receive some assistance from the state to help pay your premium or your Medicare Part B Premium.
     1. As a Specified Low-Income Medicare Beneficiary (SLMB)  Yes
 No
     2. As a Qualified Medicare Beneficiary (QMB)?  Yes
 No
     3. For other Medicaid medical benefits?  Yes
 No
D. Are you covered or will you be covered under:
Do You have or will you soon have Medicare Part A (Hospitalization)
  Yes
 No
Medicare Part A Effective Date Applicant.
Medicare Part A Effective Date Effective Date Spouse:
Dou you have or will you soon have Medicare Part B
(Medical Expenses)
  Yes
 No
Medicare Part B Effective Date Applicant:
Medicare Part B Effective Date Spouse:
Health Questions (Answer for all Insured's)
Questions 1-6 are not required of applicants applying for this coverage within 6 months of obtaining Medicare Part B, or under guaranteed issue status. If you are in your open enrollment period just skip the next 6 questions.
1. Within the past two years have you had any of the following. a. Have you been diagnosed with: Cirrhosis; Hemophilia; Multiple Sclerosis; Leukemia: Amputations Due to Diabetes?   Yes
 No
b. Have you been diagnosed with: Renal Dialysis; Kidney Dialysis; X-Ray Therapy; Radium or Chemotherapy; Degenerative (Crippling) Arthritis; Internal Cancer; Stroke?  Yes
 No
c. Have you been diagnosed with: Emphysema (under treatment); Hodgkin's Disease; Disease or Disorder of Lungs or Respiratory Systems which requires the outside assistance of a Mechanical Breathing Device?  Yes
 No
d. Have you been diagnosed with: Heart Attack; Angina; Transient Ischemic Attach (TIA); Heart Failure; Heart Surgery; Angioplasty or Coronary by-pass Surgery?  Yes
 No
e. Have you been diagnosed with: Parkinson's Disease; Alzheimer's Disease; Senile Dementia; Organic Brain Disease or other Senility Disorders?  Yes
 No
2. Are you an insulin dependent diabetic taking more than 50 units per day?  Yes
 No
3. Have you been confined to a nursing home or a wheelchair within the past 2 years or has such care been medically advised?  Yes
 No
4. Are you currently hospitalized, or receiving Medicare approved home health care; or have you been hospitalized or received Medicare approved home health care three or more times in the past 2 years?  Yes
 No
5. Within the past year have you been advised to have surgery but not had such surgery?  Yes
 No
6. Within the past 5 years, have you been diagnosed by a member of the medical profession as having any disease or disorder of the immune system, AIDS Related Complex (ARC), or have you tested positive for the HIV infection?  Yes
 No
                                                                    

 

Publications:

Medicare at a Glance

Medicare & You

Choosing A MediGap Policy

Medicare's Guide to Preventive Services

Your Guide to What Medicare Part A & B Covers
 

Home | Medicare Supplement Plan Comparison Chart Before 06/01/2010 | Medicare Supplement Plan Comparison Chart For 2013| Medicare Supplement Quote Request | Contact Us

©Copyright 2013 The Medicare Channel All Rights Reserved. This website is a general description of benefits for Medicare Supplement plans. Although every effort is made as to the accuracy of the information on this website there is always the possibility of an error. If you see an error please contact us so we can correct it. The insurance policy will always determine benefits. Please contact us for an outline of coverage provided by each of the insurance companies we represent. Not all plans are available in all areas. If you submit a quote or information request a licensed agent will contact you. We engage in insurance sales only in the states in which we are properly licensed. We are currently licensed in AL, AR, AZ, CO, FL, GA, IA, ID, IL, KS, KY, LA, MD, MI, MO, MS, NE, NM, NC, OH, OK, SC, PA, TN, TX, VA & WV. Not affiliated with, authorized by or endorsed by the U.S. government or the federal Medicare program. For more information feel free to Contact Us.

    

myspace visitor counter