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Medicare Health Plans Quote Request
Complete the following information if you would like to request a Medicare Health Plans Quote. Please understand this is not an application. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Part I - Applicant Information
Proposed Insured First Name
Last Name
Social Security #
Date of Birth
Medicare #
Age
Sex
Height
Weight
Have you used tobacco within the last 12 months?
 Yes  No
Spouse
First Name
Last Name
Social Security #
Date of Birth
Medicare #
Age
Sex
Height
Weight
Have you used tobacco within the last 12 months?
 Yes  No
Applicant Address:
Street:
City:
State:
Zip:
Phone #:
Home:
Cell:
Email Address:
Part II - Medical & General Questions
Basic Questions -
Please give details to "Yes" answers in space provided. Include insured or spouse name.
To The Best of Your Knowledge
A. Do you have a (or pending applications for) Medicare Supplement policy or certificate in force?
 Yes
 No
2. If so, do you intend to replace your current Medicare Supplement policy with this policy?  Yes
 No
B. Do you have any other health insurance coverage that provides Medicare benefits?  Yes
 No
If So, with which company?
What kind of policy?
C. Are you covered for medical assistance through the state Medicaid program?
     1. As a Specified Low-Income Medicare Beneficiary (SLMB)  Yes
 No
     2. As a Qualified Medicare Beneficiary (QMB)?  Yes
 No
     3. For other Medicaid medical benefits?  Yes
 No
D. Are you covered or will you be covered under:
Medicare Part A (Hospitalization)
 Yes
 No
Effective Date Insured:
Effective Date Spouse:
Medicare Part B (Medical Expenses)
 Yes
 No
Effective Date Insured:
Effective Date Spouse:
Health Questions (Answer for all Insureds)
Questions 1-6 are not required of applicants applying for this coverage within 6 months of obtaining Medicare Part B, or under guaranteed issue status.
1. Within the past two years have you had, or had a medical diagnosis of: a. Cirrhosis; Hemophilia; Multiple Sclerosis; Leukemia; Amputations due to Diabetes?  Yes
 No
b. Renal Dialysis; Kidney Dialysis; X-Ray Therapy; Radium or Chemotherapy; Degenerative (Crippling) Arthritis; Internal Cancer; Stroke?  Yes
 No
c. Emphysema (under treatment); Hodgkins Disease; Disease or Disorder of Lungs or Respiratory Syustem which requires the outside assistance of a Mechanical Breathing Device?  Yes
 No
d. Heart attack; angina; transient ischemic attack (TIA); heart failure; heart surgery; angioplasty or coronary by-pass surgery?  Yes
 No
e. Parkinson's disease; Alzheimer's disease; senile dementia; organic brain disease or other senility disorders?  Yes
 No
2. Are you an insulin dependent diabetic taking more than 50 units per day?  Yes
 No
3. Have you been confined to a nursing home or a wheelchair within the past two years or has such care been medically advised?  Yes
 No
4. 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 two years?  Yes
 No
5. Within the past year have you been medically advised to have surgery but not had such surgery?  Yes
 No
6. Within the past 5 years, have you been medically 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
     
 
Long Term Financial Solutions LLC

2202 N. West Shore Blvd, Suite 200 | Tampa, FL 33607
Phone 813-288-4646
Fax 813-288-4647
 
 
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