Medicare Supplemental Insurance Quote

Full Name:          
Home Address:
City:
FLORIDA     Zip Code:
Email Address: (Required) 
Home Phone:   Work Phone:   Ext.
How to Contact You: Select One Phone at Work Phone at Home Email
Date of Birth:              (mm/dd/yyyy)
Gender: Select One Male Female    Height:  ft. 
Weight:    Do you smoke? Select One Yes No

Are you a U.S. citizen? Select One Yes No

  Current Medicare Information
Are you covered under Medicare "Part A"? Select One Yes No
If "No", when will you become eligible?  (mm/dd/yyyy)

Are you covered under Medicare "Part B"? Select One Yes No
If "No", when will you become eligible?  (mm/dd/yyyy)

Are you covered for medical assistance through the state Medicaid program?
...as a specified low income Medicare beneficiary? Select One Yes No
...as a qualified Medicare beneficiary? Select One Yes No
...for other Medicaid medical benefits? Select One Yes No

Do you have another Medicare supplement
insurance policy or certificate in force? Select One Yes No
If "Yes", do you intend to replace the current
policy or certificate with this policy(certificate),
and if so, what is the termination date?
 (mm/dd/yy)

Questions for Medicare Supplement Insurance Quote
Within the last 2 years have you been aware of, diagnosed
and /or been treated by a member of the medical profession
for: heart disease or disorder, stroke, cancer, drug or alcohol
dependency, mental disorder, crohn's disease or ulcerative
colitis, nervous system disorder, liver disorder, spinal disc disease,
knee or hip disorders, or any amputation caused by disease? Select One No Yes

Have you been hospitalized within the past 12 months,
due to be so confined or been disabled for more than
5 days within the past 12 months? Select One No Yes

During the last 5 years have you been diagnosed by
a member of the medical profession as having Acquired
Immune Deficiency Syndrome (AIDS) or AIDS related
complex (ARC) or tested positive for HIV?
Select One No Yes

Do you have Parkinson's Disease or Multiple or Lateral Sclerosis? Select One No Yes

Are you currently hospitalized or confined to a nursing
facility, or are you bedridden or confined
to a wheelchair? Select One No Yes

Have you been diagnosed with Alzheimer's Disease,
senile dementia, organic brain disorder, or any other
senility disorder? Select One No Yes

Do you have kidney disease requiring dialysis or diabetes
requiring more than 50 units of insuline daily?
Select One No Yes

Do you have emphysema, Chronic Obstructive Pulmonary
Disease (COPD), or other Chronic Pulmonary disorders?
Select One No Yes

Have you been advised to have surgery or medical tests
that have not been performed? Select One No Yes

Have you used tobacco in any form during the last 12 months? Select One No Yes

Are you currently taking or have you taken any prescription
or over-the-counter medications during the last 12 months?
Select One No Yes

If you answered "Yes" to the question above please provide
the necessary information below:

Medication Name:    Dosage:
Frequency:    Condition:

Medication Name:   Dosage:
Frequency:    Condition:

Medication Name:   Dosage:
Frequency:    Condition:

Spouse Information & Health Questions

Is Spouse to be insured? Select One No Yes
Spouse: Full Name:   
Spouse Date of Birth:  (mm/dd/yyyy)
Spouse Gender: Select One Male Female
Is spouse a U.S. citizen? Select One Yes No

  Spouse Current Medicare Information
Is spouse covered under Medicare "Part A"? Select One Yes No
If "No", when will your spouse become eligible?  (mm/dd/yyyy)

Is spouse covered under Medicare "Part B"? Select One Yes No
If "No", when will your spouse become eligible?  (mm/dd/yyyy)

Is spouse covered for medical assistance through the state Medicaid program?
...as a specified low income Medicare beneficiary? Select One Yes No
...as a qualified Medicare beneficiary? Select One Yes No
...for other Medicaid medical benefits? Select One Yes No

Does spouse have another Medicare supplement insurance policy or certificate in force? Select One Yes No
If "Yes", does spouse intend to replace the current policy or certificate
with this policy(certificate), and if so, what is the termination date?
 (mm/dd/yyyy)

Questions for Medicare Supplement Insurance Quote (Spouse)
Within the last 2 years has your spouse been aware of, diagnosed
and /or been treated by a member of the medical profession for:
heart disease or disorder, stroke, cancer, drug or alcohol
dependency, mental disorder, crohn's disease or ulcerative colitis,
nervous system disorder, liver disorder, spinal disc disease, knee
or hip disorders, or any amputation caused by disease? Select One No Yes

Has spouse been hospitalized within the past 12 months, due
to be so confined or been disabled for more than 5 days within
the past 12 months? Select One No Yes

During the last 5 years has spouse been diagnosed by a member of the
medical profession as having Acquired Immune Deficiency Syndrome
(AIDS) or AIDS related complex (ARC) or tested positive for HIV?
Select One No Yes

Does spouse have Parkinson's Disease or Multiple or Lateral Sclerosis? Select One No Yes

Is spouse currently hospitalized or confined to a nursing facility,
or bedridden or confined to a wheelchair? Select One No Yes

Has spouse been diagnosed with Alzheimer's Disease, senile
dementia, organic brain disorder, or any other senility disorder?
Select One No Yes

Does spouse have kidney disease requiring dialysis or
diabetes requiring more than 50 units of insuline daily?
Select One No Yes

Does spouse have emphysema, Chronic Obstructive Pulmonary
Disease (COPD), or other Chronic Pulmonary disorders?
Select One No Yes

Has spouse been advised to have surgery or medical tests
that have not been performed? Select One No Yes

Has spouse used tobacco in any form during the last 12 months? Select One No Yes

Is spouse currently taking or has taken any prescription
or over-the-counter medications during the last 12 months?
Select One No Yes

If the answer was "Yes" to the question above please
provide the necessary information below:

Medication Name:   Dosage:
Frequency:    Condition:

Medication Name:   Dosage:
Frequency:    Condition:

Medication Name:   Dosage:
Frequency:    Condition:

Additional Information or Comments



Click on the "Submit Quote Information" button below to send
your Florida Medicare supplement insurance quote request.**

**Information received from this Florida Medicare Supplement Insurance quote request form sent to Johnson and Associates, will be for our use only and will not be sold, given to or distributed to any other parties. A quote will be based on the Medicare Supplement insurance policy information provided and does not guarantee acceptance of the risk by us. The precise coverage afforded is subject to meeting underwriting guidelines, and the terms, conditions and exclusions of the policy as issued. By submitting this request you acknowledge that this is neither an offer to insure nor a guarantee of insurance. Completion of this form does not entitle you to a Florida Medicare Supplement Insurance policy. We are licensed in Florida and will not provide quotes for other states.

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