Medigap Tool Underwriting Medicare Supplement Agent Selection*Dan OwensKelly OwensName First Last PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Gender*FemaleMaleBirth Date:* MM DD YYYY What is your current plan?*Plan GPlan FMedicare Advantange (Part C)What is your monthly premium?Do you live with anybody?NoYesAnswer for potential Household DiscountsHeightWeightWithin the past 12 months, have you used any nicotine based products, any form of electronic cigarette (including nicotine-free electronic cigarettes), or marijuana?NoYesAre you dependent on a wheelchair or any motorized mobility device?NoYesWithin 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?NoYesAt 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, defibrillatorNoYesB. leukemia, lymphoma, multiple myeloma, cirrhosisNoYesC. Parkinson's Disease, Lou Gehrig's Disease, Alzheimer's Disease, dementia, multiple sclerosis, muscular dystrophy, cerebral palsyNoYesD. chronic kidney disease, kidney failure, kidney disease, requiring dialysis, renal insufficiency, Addison's DiseaseNoYesE. any condition requiring a bone marrow transplant or stem cell transplant, any condition requiring an organ transplantNoYesF. AIDS or HIVNoYesHave you been medically diagnosed or treated by a member of the medical profession for diabetes?A. that requires use of insulin?NoYesHow many units of insulin daily?B. do you take medication for high blood pressure in addition to diabetes?NoYesHow many blood pressure medications do you take?C. with complications including retinopathy, neuropathy, peripheral vascular or arterial disease or heart artery blockage*NoYesD. with a history of heart attack or strokeNoYesIf yes, when was this?E. treated with medication that has been changed or adjusted in the past 12 months because of uncontrolled blood sugar*NoYesWhat 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 abuseNoYesB. cardiomyopathy, anemia requiring requiring repeated blood transfusions, or any other blood disorderNoYesC. Atrial fibrillationNoYesWhen was your last episode/event of atrial fibrillation?D. internal cancer, melanoma, Hodgkin's DiseaseNoYesWhen was your last treatment for cancer or melanoma?E. hepatitis, disorder of the pancreasNoYesWithin 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 diseaseNoYesB. myathenia gravis, systemic lupus or connective tissue disorderNoYesC. osteoporosis with fractures, Paget's Disease, arthritis that restricts mobility or the activities of daily livingNoYesD. any lung or respiratory disorder requiring the use of a nebulizer or oxygen, or 3 or more medications for lung or respiratory disorderNoYesE. any lung or respiratory disorder and currently use tobacco productsNoYesMedicationsDo you take any medications?*NoYesList Your Medications:Medication Name:Condition:Dosage:Times per day:Date Prescribed: Provide details:Upload a file if needed: Drop files here or 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.
