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Alabama Medicare Supplement Quote Form

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

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Personal Information

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Birth Date *

Current age *

Social Security Number

Height *

Weight *

Sex *

Male
Female

Are you a legal resident of the United States? *

Yes
No

Have you used Tobacco in any form in the last 12 months? *

No
Yes

Medicare Card Number (if you haven't applied yet -say "Have not Applied" *

Did you turn 65 in the last 6 months? *

No
Yes

Did you enroll in Medicare Part B in the last 6 months? *

No
Yes

If "Yes", what effective date?

Are you covered for state assistance through the state Medicaid program? *

No
Yes

A. If "Yes" to above, will Medicaid pay your premiums for this Medicare Supplement policy?

No
Yes
Not Applicable

B. Do you receive any benefits from Medicaid other than your payments toward your Medicare Part B premium? *

No
Yes
Not Applicable

If you have had coverage from any other Medicare plan, other than original Medicare within the last 63 days (for example, a Medicare Advantage Plan, or a Medicare HMO or PPO plan) fill in your start date below.

List your end dates below. If you are still on this plan, leave the this field blank.

A. If you are still covered under the Medicare plan, do you intend to replace your current policy with this new Medicare Supplement Policy?

Yes
No
Not applicable

B. Was this your first time in this type of Medicare plan?

Yes
No
Not Applicable

C. Did you drop a Medicare Supplement policy to enroll in this Medicare plan?

Yes
No
Not Applicable

Do you have another Medicare Supplement policy in force? *

No
Yes
Not Applicable

If "Yes", what company is your policy with?

If "Yes", what type of plan do you currently have?

If you have a current Medicare Supplement policy in place, do you intend to replace that policy with this new one? *

No
Yes
Not Applicable

Have you had coverage under any other Health Insurance within the past 63 days? (For example, an employer, union or individual health insurance)? *

No
Yes

If "Yes", what company was the policy with?

If "Yes" what type of plan was it?

If you had coverage with another policy in the past 63 days, what was the start date of that policy?

What was the end date of that policy? If you are still covered, leave this question blank.

Are you dependent on a wheelchair or any other motorized mobility vehicle? *

No
Yes

Do any of the following apply to you? (Check all that apply)

None of these applyCurrently hospitalized
Confined to a bedIn a nursing facility
In an assisted living faciltyReceiving home health care
Receiving physical therapy

At any time, have you been medically diagnosed, treated, or had surgery for any of the following?

None of these applyCongestive heart failure
Unoperated aneurysmDefibrilator
LeukemiaLymphoma
Multiple myelomaCirrhosis
Parkinson's DiseaseLou Gehrig's Disease
Alzheimer's DiseaseDementia
Multiple sclerosisMuscular dystrophy
Cerebral palsyChronic kidney disease
Kidney failureKidney disease requiring dialysis
Renal insufficiencyAddison's Disease
Any Condition requiring a bone marrow transplantStem cell transplant
Any condition requiring organ transplantAquired Immune Deficiency Syndrome (AIDS)
AIDS Related Complex (ARC)Tested positive for HIV

Do you have diabetes that requires the use of insulin? *

No
Yes

Do you have diabetes with complications including retinopathy, neuropathy, peripheral vascular or arterial disease or heart artery blockage? *

No
Yes

Do you have diabetes with history of heart attack or stroke (at any time)? *

No
Yes

Do you have diabetes treated with medication that has been changed or adjusted in the past 12 months because of uncontrolled blood sugar? *

No
y

Within the past 36 months, have you been medically diagnosed, treated, or had surgery for any of the following?:

None of these applyAlcoholism or drug abuse
Cardiomyopathy, atrial fibrilationAnemia requiring blood transfusions
Any other blood disorderInternal cancer, melanoma or Hodgkin's Disease
Hepatitis, disorder of the pancreas

Within the past 24 months, have you been medically diagnosed, treated, or had surgery for any of the following?

None of these applyEnlarged Heart?
Transient Ischemic attack (TIA)Stroke
Peripheral vascular or arterial diseaseNeuropathy
Amputation caused by disease

Within the past 24 months, have you been medically diagnosed, treated, or had surgery for any of the following?

None of these apply
Myasthenia gravis
Systemic lupus
Connective tissue disorder

Within the past 24 months, have you been medically diagnosed, treated, or had surgery for any of the following?

None of these apply
Osteoporosis with fractures
Paget's Disease
Arthritis that restricts mobility
Arthritis that restricts daily living activities

Within the past 24 months, have you been medically diagnosed, treated, or had surgery for any of the following?

None of these applyAny lung or respirator disorder
Disorder requiring use of nebulizerDisorder requiring use of oxygen
Disorder requiring 3+ medications for breathingAny lung disorder and currently use tobacco

Within the past 12 months have you been advised by a medical professional to have:

None of these apply
Treatment that has not been performed
Further evaluation that has not been performed
Diagnostic testing that has not been performed
Any surgery that has not been performed

Within the past 12 months, have you been medically diagnosed, treated, or had surgery for any of the following?

None of these apply
Heart attack
Artery blockage
Heart valve disorder

Within the past 12 months, do any of the following apply to you?

None of these applyHad a pacemaker implanted
Had a history of prostate cancerHad a PSA greater than 4.5 if under age 70
Had a PSA greater than 6.5 if age 70 or olderHad a seizure

Was your last blood pressure reading higher than 175 systolic or higher than 100 Diastolic? *

No
Yes

Within the past 24 months if you have been medically diagnosed, treated or had surgery for any of the following:

None of these apply
Brain
Mental disorder
Nervous disorder

If you answered yes to previous question, what was the reason and diagnosis?

Within the past 5 years, have you been?

None of these apply
Hospitalized
Treated in an outpatient facility
Emergency room

If you answered yes to previous question, what was the reason and diagnosis?

List any prescribed medications and reasons for taking

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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