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SSL
Part I - Applicant Information
* First Name
* Last Name
Birth Date
Medicare #
Age
Sex
Height
Weight
Have you used tobacco within the last 12 months?
Yes
No
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?
Yes
No
If yes, please describe
2. If so, do you intend to replace your current Medicare Supplement policy with this policy?
Yes
No
If yes, please describe
B. Do you have any other health insurance coverage that provides Medicare benefits?
Yes
No
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)
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:
Medicare Part A (Hospitalization)
Yes
No
Effective Date Insured:
Effective Date Spouse:
Medicare Part B (Medical Expenses)
Yes
No
Effective Date Insured:
Effective Date Spouse:
Health Questions (Answer for all Insureds)
Within the past two (2) years for (a) through (e) have you had, or had a medical diagnosis of:
The below questions are not required of applicants applying for this coverage within 6 months of obtaining Medicare Part B, or under guaranteed issue status.
a. Cirrhosis; Hemophilia; Multiple Sclerosis; Leukemia; Amputations due to Diabetes?
Yes
No
b. Renal Dialysis; Kidney Dialysis; X-Ray Therapy; Radium or Chemotherapy; Degenerative (Crippling) Arthritis; Internal Cancer; Stroke?
Yes
No
c. Emphysema (under treatment); Hodgkins Disease; Disease or Disorder of Lungs or Respiratory Syustem which requires the outside assistance of a Mechanical Breathing Device?
Yes
No
d. Heart attack; angina; transient ischemic attack (TIA); heart failure; heart surgery; angioplasty or coronary by-pass surgery?
Yes
No
e. 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 two 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 two years?
Yes
No
5. Within the past year have you been medically advised to have surgery but not had such surgery?
Yes
No
6. Within the past 5 years, have you been medically 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
Before submitting, type in required validation security code:
60g7g5
* Required Fields