Medicare Supplement Eligibility

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1. Tell us a little about yourself.

Tell us a little about yourself. Name:
Address:
City/Town:
State:
ZIP/Postal Code:
Phone Number:

In certain situations, Medicare Supplemental coverage is Guaranteed Issue, meaning there is no medical underwriting to go through. To see if this pertains to you, please answer the following:

2. Do any of these situations apply to you?

Do any of these situations apply to you? You've lost or dropped employer-sponsored coverage

Your Medicare Advantage Plan stops coverage in your area

You moved out of a service area, covered by your Medicare Advantage Plan

Your Medicare Supplement or Medicare Advantage Plan violated its contract with you

Your Medicare Supplement or Advantage Plan involuntarily terminated coverage (for example, it went bankrupt)

You dropped a Medicare Supplement to enroll in a Medicare Advantage Plan, then dropped the Medicare Advantage Plan within 2 years

On first becoming eligible for Medicare Part A at age 65, you enrolled in a Medicare Advantage Plan, then dropped it within 2 years

Eligibility for coverage and the rates charged for Medicare Supplement Plans vary based on the time that has elapsed from your 65th birthday or Medicare Part B effective date, if later. Please provide the following information, so that we can provide you quote for coverage:

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3. Determine Time Elapsed Since 65th Birthday and Medicare Part B Effective Date

Determine Time Elapsed Since 65th Birthday and Medicare Part B Effective Date Date of Birth
Part B Effective Date
ZIP/Postal Code:
Email Address:
Phone Number:

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4. Do you have End Stage Renal Disease, or are you currently receiving dialysis, or have you been diagnosed, within the past 90 days, with kidney disease that requires dialysis?

Do you have End Stage Renal Disease, or are you currently receiving dialysis, or have you been diagnosed, within the past 90 days, with kidney disease that requires dialysis? Yes

No

5. Please provide any details regarding a pre-existing condition that must be considered during the underwriting process.

Please provide any details regarding a pre-existing condition that must be considered during the underwriting process.

Thank you for your information. We will contact you with a preliminary quote for coverage. Rates are subject to change. Actual rate will be determined upon acceptance into the plan, based on eligibility criteria, and your medical conditions.

1. Default Section

1. Tell us a little about yourself.

2. Do any of these situations apply to you?

3. Determine Time Elapsed Since 65th Birthday and Medicare Part B Effective Date

4. Do you have End Stage Renal Disease, or are you currently receiving dialysis, or have you been diagnosed, within the past 90 days, with kidney disease that requires dialysis?

5. Please provide any details regarding a pre-existing condition that must be considered during the underwriting process.