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Medicare Supplement Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!


Your Personal Data

Your Name:
Street Address:
City:
Your "County" is?
State: (Must be New York)
Zip Code:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 
Marital Status:
Single Married
Are You Retired?
Yes No
 
Health Ins. Currently?
(If yes, list carrier, and # of years
continuous. If none, type N/C)
 
Rate Your Credit History and Past Insurance Payment History:
(Some companies products are
based on your credit and payment history.)
Excellent Fair
Poor Horrible


UNDERWRITING INFORMATION
 
Insured Name: Birthdate:
Insured Height: Insured Weight:
Insured Occupation: Sex (M/F):
Taking Medication?
(if yes, describe)
Medication Cost:
(per month)
 
Do you want your
Medicare Supplement
To Include Any
Medication Costs?

(If yes, descibe in detail, and to which of the insured persons they apply.)
 
 
When Do You Want Coverage to Begin?
 
Any special coverages needed?
(Tell us what you want your plan to do for you!)
 
Tell Us What You Want MOST in your Medicare Plan, or list any other Remarks here:


Send my quotation via: E-Mail Fax
Regular Mail
Call me by Phone!

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

Yes, I Agree. Please Send Me My
Medicare Supplement Quote NOW!


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