South FL Medicare Supplement Insurance Quote

We provide affordable Florida medicare supplement insurance quotes to the
following south Florida counties and cities: Miami-Dade County, Broward
County, Palm Beach County, Coral Gables, Kendall, Richmond Heights,
Pinecrest, Howard, Coral Way Village, Westchester, Westwood Lakes,
Brownsville, Sweetwater, Key Biscayne, North Bay Village, Miami Beach, Miami
Springs, Virginia Gardens, Hialeah, El Portal, Miami Shores, Indian Creek,
Surfside, Bal Harbour, North Miami, Biscayne Park, Pinewood Park, Opa Locka,
Bunche Park, Hialeah Gardens, Palm Springs North, Carol City, Miami, Norland,
Ojus, Miami Lakes, Biscayne Gardens, Hallandale, Sunny Isles Beach, Golden
Beach, Aventura, Uleta, Miramar, Pembroke Pines, North Miami Beach,
Hallandale Beach, Ives Estates, Pembroke Park, Hollywood, Dania Beach,
Cooper City, Davie, Weston, Plantation, Playland Isles, Melrose Park,
Lauderhill, Sunrise, Tamarac, Fort Lauderdale, Wilton Manors, Oakland Park,
Lauderdale Lakes, Sea Ranch Lakes, Pompano Beach, Margate, Coral Springs,
North Lauderdale, Lighthouse Point, Hillsboro Beach, Coconut Creek, Deerfield
Beach, Boca Raton, The Hamptons, Highland Beach, Boca West, Delray Beach,
Boca Pointe, Boynton Beach, Lantana, Rainbow Lakes, Atlantis, Lake Worth,
South Palm Beach, Palm Springs, Greenacres, Wellington, Haverhill, Palm
Beach, Golden Lakes, Riviera Beach, Glen Ridge, West Palm Beach, Lake Park,
Royal Palm Beach, Jupiter, Juno Beach, North Palm Beach, Loxahatchee, Belle
Glade, Palm Beach Shores, South Miami, Cutler Ridge, Princeton, Perrine,
Naranja, Homestead, Florida City, and Leisure City, FL

Full Name:
Home Address:
City:    FLORIDA   Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Date of Birth:             (mm/dd/yyyy)

Are you a U.S. citizen?
Do you have an Alien Registration Receipt Card?
Card Number:
U.S. Arrival Date: (mm/dd/yyyy)

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

Are you covered under Medicare "Part B"?
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?
...as a qualified Medicare beneficiary?
...for other Medicaid medical benefits?

Do you have another Medicare supplement insurance
policy or certificate in force?
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)

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?

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?

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?

Do you have Parkinson's Disease or Multiple or Lateral Sclerosis?

Are you currently hospitalized or confined to a nursing facility, or are you bedridden or
confined to a wheelchair?

Have you been diagnosed with Alzheimer's Disease, senile dementia, organic brain disorder,
or any other senility disorder?

Do you have kidney disease requiring dialysis or diabetes requiring more than 50 units
of insuline daily?

Do you have emphysema, Chronic Obstructive Pulmonary Disease (COPD), or other
Chronic Pulmonary disorders?

Have you been advised to have surgery or medical tests that have not been performed?

Have you used tobacco in any form during the last 12 months?

Are you currently taking or have you taken any prescription or over-the-counter
medications during the last 12 months?

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

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

                                         Is Spouse to be insured?
Spouse: Full Name:
Spouse Date of Birth: (mm/dd/yyyy)
Spouse Gender:
Is spouse a U.S. citizen?
Does spouse have an Alien Registration Receipt Card?
Card Number:
Spouse's U.S. Arrival Date: (mm/dd/yyyy)

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

Is spouse covered under Medicare "Part B"?
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?
...as a qualified Medicare beneficiary?
...for other Medicaid medical benefits?

Does spouse have another Medicare supplement insurance policy or certificate in force?
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)

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?

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?

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?

Does spouse have Parkinson's Disease or Multiple or Lateral Sclerosis?

Is spouse currently hospitalized or confined to a nursing facility, or bedridden or
confined to a wheelchair?

Has spouse been diagnosed with Alzheimer's Disease, senile dementia, organic brain disorder,
or any other senility disorder?

Does spouse have kidney disease requiring dialysis or diabetes requiring more than 50 units
of insuline daily?

Does spouse have emphysema, Chronic Obstructive Pulmonary Disease (COPD), or other
Chronic Pulmonary disorders?

Has spouse been advised to have surgery or medical tests that have not been performed?

Has spouse used tobacco in any form during the last 12 months?

Is spouse currently taking or has taken any prescription or over-the-counter
medications during the last 12 months?

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

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Comments / Additional Information:

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