Medigap Tool Underwriting Medicare Supplement Agent Selection* Dan Owens Kelly Owens Name First Last PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Gender* Female Male Birth Date:* Month Day Year What is your current plan?* Plan G Plan F Medicare Advantange (Part C) What is your monthly premium? Do you live with anybody? No Yes Answer for potential Household DiscountsHeight Weight Within the past 12 months, have you used any nicotine based products, any form of electronic cigarette (including nicotine-free electronic cigarettes), or marijuana? No Yes Are you dependent on a wheelchair or any motorized mobility device? No Yes Within the past 12 months, have you been advised by a medical professional to have treatment, further evaluation, diagnostic testing, or any surgery that has not been performed? No Yes At any time, have you been diagnosed or treated by a member of the medical profession or had surgery for any of the following?A. Congestive heart failure, unoperated aneurysm, defibrillator No Yes B. leukemia, lymphoma, multiple myeloma, cirrhosis No Yes C. Parkinson's Disease, Lou Gehrig's Disease, Alzheimer's Disease, dementia, multiple sclerosis, muscular dystrophy, cerebral palsy No Yes D. chronic kidney disease, kidney failure, kidney disease, requiring dialysis, renal insufficiency, Addison's Disease No Yes E. any condition requiring a bone marrow transplant or stem cell transplant, any condition requiring an organ transplant No Yes F. AIDS or HIV No Yes Have you been medically diagnosed or treated by a member of the medical profession for diabetes?A. that requires use of insulin? No Yes How many units of insulin daily? B. do you take medication for high blood pressure in addition to diabetes? No Yes How many blood pressure medications do you take? C. with complications including retinopathy, neuropathy, peripheral vascular or arterial disease or heart artery blockage* No Yes D. with a history of heart attack or stroke No Yes If yes, when was this? E. treated with medication that has been changed or adjusted in the past 12 months because of uncontrolled blood sugar* No Yes What was your last A1C reading? Have you ever been diagnosed or treated by a member of the medical profession or had surgery for any of the following?A. alcoholism, drug abuse No Yes B. cardiomyopathy, anemia requiring requiring repeated blood transfusions, or any other blood disorder No Yes C. Atrial fibrillation No Yes When was your last episode/event of atrial fibrillation? D. internal cancer, melanoma, Hodgkin's Disease No Yes When was your last treatment for cancer or melanoma? E. hepatitis, disorder of the pancreas No Yes Within the last 24 months, have you been diagnosed or treated by a member of the medical profession or had surgery for any of the following?A. enlarged heart, TIA, stroke, peripheral vascular or arterial disease, neuropathy, amputation caused by disease No Yes B. myathenia gravis, systemic lupus or connective tissue disorder No Yes C. osteoporosis with fractures, Paget's Disease, arthritis that restricts mobility or the activities of daily living No Yes D. any lung or respiratory disorder requiring the use of a nebulizer or oxygen, or 3 or more medications for lung or respiratory disorder No Yes E. any lung or respiratory disorder and currently use tobacco products No Yes MedicationsDo you take any medications?* No Yes List Your Medications:Medication Name:Condition:Dosage:Times per day:Date Prescribed: Provide details:Upload a file if needed: Drop files here or Select files Max. file size: 2 MB, Max. files: 3. Consent* I agree to the privacy policy.You understand this is not an application for Medicare Supplement Insurance, this is to provide you with quotes as requested. The questions answered will not disclose any personal information nor share your personal information with third parties.
