Posts Tagged ‘healthcare plans’

Medicare Healthcare Plans Quote

Wednesday, May 26th, 2010

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Part I – Applicant Information

Name
Social Security Number
Birth Date
Medicare #
Age
Sex
Height
Weight
Have you used tobacco within the last 12 months?
Spouse Information
Name
Social Security Number
Birth Date
Medicare #
Age
Sex
Height
Weight
Have you used tobacco within the last 12 months?
Applicant Address
Street Address
City
State
Zip Code
Phone Number
Alternate Telephone
Email Address
Part II - Medical & General questions - Please give details to "yes". Include insured or spouse name.
A. Do you have a (or pending applications for) Medicare Supplement policy or certificate in force?
If yes, please describe
2. If so, do you intend to replace your current Medicare Supplement policy with this policy?
If yes, please describe
B. Do you have any other health insurance coverage that provides Medicare benefits?
If so, with which company?
What kind of policy?
C. Are you covered for medical assistance through the state Medicaid program:
1. As a Specified Low-Income Medicare Beneficiary (SLMB)
2. As a Qualified Medicare Beneficiary (QMB)
3. For other Medicaid medical benefits?
D. Are you covered or will you be covered under:
Medicare Part A (Hospitalization)
Effective Date Insured:
Effective Date Spouse:
Medicare Part B (Medical Expenses)
Effective Date Insured:
Effective Date Spouse:
Health Questions (Answer for all Insured)
Within the past two (2) years have you had, or had a medical diagnosis of:
a. Cirrhosis; Hemophilia; Multiple Sclerosis; Leukemia; Amputations due to Diabetes?
b. Renal Dialysis; Kidney Dialysis; X-Ray Therapy; Radium or Chemotherapy; Degenerative (Crippling) Arthritis; Internal Cancer; Stroke?
c. Emphysema (under treatment); Hodgkins Disease; Disease or Disorder of Lungs or Respiratory Syustem which requires the outside assistance of a Mechanical Breathing Device?
d. Heart attack; angina; transient ischemic attack (TIA); heart failure; heart surgery; angioplasty or coronary by-pass surgery?
e. Parkinson's disease; Alzheimer's disease; senile dementia; organic brain disease or other senility disorders?
2. Are you an insulin dependent diabetic taking more than 50 units per day?
3. Have you been confined to a nursing home or a wheelchair within the past two years or has such care been medically advised?
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 two years?
5. Within the past year have you been medically advised to have surgery but not had such surgery?