Form Preview Medicare Supplement Shopping Questionnaire Name * Date of Birth * Phone Number * Email * State of Residence * Zipcode * Current Plan * Plan G Plan F Plan N Plan High Deductible G (or F) Other Unsure Change Preference (check all that apply) * I want to see if there is a lower rate for the same benefits I have now I would be willing to look at a higher out of pocket risk to save money on premium Current Plan Premium * Frequency * Monthly Quarterly SemiAnnual Annual Did you receive a notice that your premiums are going up? * Yes No Date of Rate Increase * New Premium after Increase * 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.* * Tobacco Use * Choose Option Yes No Congestive Heart Failure * Yes No Details Diabetes With History of Heart Attack or Stroke * Yes No Details Internal Cancer or Melanoma * Yes No Details Diabetes With Complications (Retinopathy, Neuropathy, Peripheral Vascular or Arterial Disease) * Yes No Details Kidney or Liver Disease * Yes No Details Atrial Fibrillation, TIA or Stroke * Yes No Details Diabetes With Insulin Use * Yes No Details Osteoporosis With Fractures * Yes No Details Parkinson's Disease, Rheumatoid Arthritis or Multiple Sclerosis * Yes No Details Are you currently receiving Physical Therapy? * Yes No Details Do you have any scheduled surgery or treatment in the next 12 months? * Yes No Details Would you like us to discuss other insurance options with you? Please check off any other plans you would like us to review: Dental Coverage Vision Coverage Hearing Aid Coverage Nursing Home and/or Home Health Aid Coverage Not Interested at This Time If you are human, leave this field blank. Submit