Current Medicare Information
Are you covered under Medicare "Part A"?	Y   N
If "No", when will you become eligible? (mm/dd/yy)
Are you covered under Medicare "Part B"?	Y   N
If "No", when will you become eligible? (mm/dd/yy)

Health Questions
If you are applying for coverage during open enrollment or during a Guaranteed issue period you do not need to answer questions (A. thru L.).
(A.)   Are you currently hospitalized or confined to a nursing facility; or, are you bedridden or confined to a wheelchair?	Y   N
(B.)   Do you have emphysema, Chronic Obstructive Pulmonary Disease (COPD) or other Chronic Pulmonary disorders?	Y   N
(C.)   Do you have Parkinson's Disease or Multiple or Lateral Sclerosis?	Y   N
(D.)   Have you been diagnosed with Alzheimer's Disease, senile dementia, organic brain disorder, or any other senility disorder?	Y   N
(E.)   Have you been diagnosed with or treated for Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?	Y   N
(F.)   Do you have kidney disease requiring dialysis or diabetes requiring more than 50 units of insulin daily?	Y   N
(G.)   Within the past two years have you been treated for or been advised by a physician to have treatment for internal cancer, alcoholism, or drug abuse; cirrhosis; mental or nervous disorder requiring psychiatric care; or have you had any amputation caused by disease?	Y   N
(H.)   Within the past two years have you been treated for or been advised by a physician to have treatment for heart, coronary or carotid artery disease (not including high blood pressure); peripheral vascular disease; congestive heart failure or enlarged heart; stroke; transient ischemic attacks (TIA); or heart rhythm disorders?	Y   N
(I.)   Within the past two years have you been treated for osteoporosis, degenerative bone disease, or crippling arthritis?	Y   N
(J.)   Have you been advised that surgery may be required within the next twelve months for cataracts?	Y   N
(K.)   Have you been advised to have surgery or medical tests that have not been performed?	Y   N
(L.)   Have you been hospital confined three or more times in the last two years?	Y   N

Additional Health Questions
Have you used tobacco in any form in the past 12 months?	Y   N
Are you taking or have you taken any prescription or over-the-counter medications within the past 12 months? If you answered "Yes", please list the drug and the condition below:	Y   N
Medication Name (copy off pharmacy label) Dosage Frequency Reason Please list any additional medications in the "Additional Comments" section at the bottom of this form

Additional Medicare Questions
Do you have another Medicare supplement insurance policy or certificate in force?	Y   N
If "Yes", do you intend to replace your current Medicare supplement policy or certificate with this policy (certificate), and if so, indicate the termination date (mm/dd/yy)?	Y   N
Are you covered for medical assistance through the state Medicaid program:
... As a Specified Low Income Medicare Beneficiary (SLMB)?	Y   N
... As a Qualified Medicare Beneficiary (QMB)?	Y   N
... For other Medicaid medical benefits?	Y   N

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you had additional medications you could not list above or other information where there was not enough space, please enter them here.

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