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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 *

Are you a legal resident of the United States? *

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

Medicare Card Number (if you haven't applied yet -say "Have not Applied" *
Did you turn 65 in the last 6 months? *

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

If "Yes", what effective date?
/ /
Are you covered for state assistance through the state Medicaid program? *

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


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


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?


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


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


Do you have another Medicare Supplement policy in force? *


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? *


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

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? *

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






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

























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

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

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

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

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






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






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



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




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





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




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



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





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

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



If you answered yes to previous question, what was the reason and diagnosis?
Within the past 5 years, have you been?



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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