Discounts
Please Complete the Following
Medicare Supplement Activity Tracker Discount Authorization
Form
Previous or Existing Coverage Information
Please Complete the Following to the Best of Your Knowledge and
Belief
If you lost or are losing other health insurance
coverage
and
received a notice from your prior insurer saying you are eligible for guaranteed issue of a
Medicare
Supplement insurance policy, or that you had certain rights to buy such a policy, you may be
guaranteed acceptance in one or more of our Medicare Supplement plans. Please include a copy of
the
notice from your prior insurer with this Application. Please mark Yes or No below with an “X”,
to
the best of your knowledge.
NOTE TO APPLICANT: If you are participating in a "Spend Down
Program"
and have not met your "Share of the Cost", please answer No to this question.
Health Information
Please answer to the best of your knowledge and belief
Within the past 2 years have you been diagnosed, treated, evaluated, or
prescribed
medication
for any
of the following?
Cancer for diagnosed, treated, evaluated, or prescribed medication in past 2 years.
Cardiovascular for diagnosed, treated, evaluated, or prescribed medications in past 2 years In
the Past two years have you been diagnosed, treated, evaluated or prescribed meds or any of
the following?
Circulatory disease for diagnosed, treated, evaluated, or prescribed medication
in
past 2
years:
Neurological for diagnosed, treated, evaluated, or prescribed medication in past 10
years
Other for diagnosed, treated, evaluated, or prescribed medication in past 2
years:
