1Source Financial Solutions, Inc. - Medicare Supplement Quote

Medicare Supplement Quote

Complete the following information if you would like to request a Medicare Supplement Quote. Please understand this is not an application. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Part I - Applicant Information
Proposed Insured	First Name
	Last Name
	Social Security #
	Date of Birth
	Medicare #
	Age
	Sex
	Height
	Weight
	Have you used tobacco within the last 12 months? Yes No
Spouse	First Name
	Last Name
	Social Security #
	Date of Birth
	Medicare #
	Age
	Sex
	Height
	Weight
	Have you used tobacco within the last 12 months? Yes No
Applicant Address:	Street:
	City:
	State:
	Zip:
	Phone #:	Home: Cell:
	Email Address:
Part II - Medical & General Questions
Basic Questions - Please give details to "Yes" answers in space provided. Include insured or spouse name.
To The Best of Your Knowledge A. Do you have another (or pending applications for) Medicare Supplement policy or certificate in force?		Yes No

2. If so, do you intend to replace your current Medicare Supplement policy with this policy?		Yes No

B. Do you have any other health insurance coverage that provides benefits similar to this Medicare Supplement Policy?		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)
Questions 1-6 are not required of applicants applying for this coverage within 6 months of obtaining Medicare Part B, or under guaranteed issue status.
1. Within the past two years have you had, or had a medical diagnosis of:	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
Part III - Coverage For
Coverage For:
Medicare Supplement Plan	Insured:
Medicare Supplement Plan	Spouse:
Name of Preferred Hospital

Securities offered through Quest Capital Strategies | 25231 Paseo De Alicia, Suite #110 | Laguna Hills, CA 92653 | (949) 830-4885

Voice: 678-569-2415 Fax: 678-569-2416

Site hosted by: Cooper e.Business Solutions