347 N. Pottstown Pike, Suite 200 | Exton, PA 19341

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Medicare Supplement Shopping Questionnaire
Change Preference (check all that apply)
Did you receive a notice that your premiums are going up?

Shopping Medicare Supplement plans requires medical underwriting, please indicate if you have been diagnosed or treated with any of the following health conditions in the last five years: *Answering the health questions below allows us to determine which insurance company may be the most appropriate based on your health history.* *

Congestive Heart Failure *
Diabetes With History of Heart Attack or Stroke *
Internal Cancer or Melanoma *
Diabetes With Complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease) *
Kidney or Liver Disease *
Atrial Fibrillation, TIA or Stroke *
Diabetes With Insulin Use *
Osteoporosis With Fractures *
Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis
Are you currently receiving Physical Therapy? *
Do you have any scheduled surgery or treatment in the next 12 months? *
Would you like us to discuss other insurance options with you? Please check off any other plans you would like us to review: