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MEDICARE SUPPLEMENT INSURANCE:

People who want to supplement their Medicare hospital and medical coverage may apply for Medicare supplement insurance because:

bulletMedicare does not cover all health care bills
bulletMedicare has deductibles and co-payments for some services
bulletthe full amount for services not covered by Medicare must be paid...and Medicare Supplement coverage can help pay some of the costs Medicare doesn’t cover

What do most Medicare Supplement  plans offer?
Other than paying these bills out of your own pocket, which not everyone can afford, you may select a Medicare supplement insurance policy to:
bullethelp reduce out-of-pocket costs for hospital, doctor and other medical expenses that Medicare does not cover
bullethelp protect your retirement savings from escalating medical costs

Depending on the coverage you select and where you live, a Medicare supplement insurance policy may help pay some of the expenses not paid by Medicare such as:
bulletPart A deductible and
bulletskilled nursing facility care
bulletextended hospital care
bulletphysicians’ services, hospital outpatient services and supplies, ambulance service, physical and speech therapy
bullethealth care received outside the U.S.

What’s more, most Medicare Supplement policies should include coverage's such as:
bulletchanges as Medicare changes
bulletis guaranteed renewable
bulletoffers a no-risk 30-day free look – return the policy for a refund if the coverage does not meet your satisfaction

 

Name:
Address:
City:
State:
ZIP Code:
Phone:
FAX:
E-mail Address:
Date Of Birth: / /
Sex:
Tobacco User Within Past 12 Months:
Have you been diagnosed with: Cirrhosis; Hemophilia; Multiple Sclerosis; Leukemia: Amputations Due to Diabetes? Yes
No 
Have you been diagnosed with: Renal Dialysis; Kidney Dialysis; X-Ray Therapy; Radium or Chemotherapy; Degenerative (Crippling) Arthritis; Internal Cancer; Stroke? Yes
No
Have you been diagnosed with: Emphysema (under treatment); Hodgkin's Disease; Disease or Disorder of Lungs or Respiratory Systems which requires the outside assistance of a Mechanical Breathing Device? Yes
No
Have you been diagnosed with: Heart Attack; Angina; Transient Ischemic Attach (TIA); Heart Failure; Heart Surgery; Angioplasty or Coronary by-pass Surgery? Yes
No
Have you been diagnosed with: Parkinson's Disease; Alzheimer's Disease; Senile Dementia; Organic Brain Disease or other Senility Disorders? Yes
No
Have you been confined to a nursing home or a wheelchair within the past 2 years or has such care been medically advised? Yes
No
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 2 years? Yes
No
Within the past year have you been advised to have surgery but not had such surgery? Yes
No
Within the past 5 years, have you been 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

Spouse Information
(if applicable)

Name:
Date Of Birth  / /
Sex:
Tobacco User Within Past 12 Months: