Senior Insurance

 
We'll begin by asking for a little information about you. Your answers to the following questions will enable us to determine whether a medicare supplement is a wise choice for your present and future insurance needs.
What is your gender? M F
What is your date of birth?
MM
  / 
DD
  / 
YYYY
If you are age 65 or over, are you eligible for Medicaid? Yes No
What is your height? ft. in.
What is your weight? lbs.
Please indicate your marital status:
What is the highest level of education you completed?
Please indicate your current employment status:
Please select the industry that best describes your occupation:
How long have you been employed at your present job? Years Months

To help us ensure that our search delivers the most competitive quote for your insurance needs, we'll need some information about your day-to-day lifestyle, your medical history and your current health status. Please continue by answering the following set of questions to the best of your knowledge
In the past five years, have you used any form of tobacco or nicotine substitute?
If Yes, what forms of tobacco did you use? Smoke Cigarettes
Smoke Cigars
Smoke A Pipe
Chew Tobacco
Chew Nicotine Gum
'The Patch'
If you currently smoke cigarettes, how many packs do you smoke per day?
Have you used any form of alcohol in the past five years? Yes No
If so, what do you usually drink? Beer
Wine
Liquor
Have you been treated by a physician in the last year? Yes No
Have you been hospitalized in the last five years? Yes No
Are you currently taking any prescription medications? Yes No
Do you visit your doctor for annual check-ups? Yes No

Company Name (DBA):
Name: Mr. Mrs. Ms.
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip Code:
What is the best way for us to get in touch?
Home Telephone: - -
Work Telephone: - - Ext.
Cell Telephone: - -
Fax: - -
Email:
Please confirm the email address
Best Time To Contact:
Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.