MEDICARE
Policy Requested
*What coverage package do you wish?
Medicare Advantage
Medicare Supplemental
Medicare Part D
Other Medicare
Personal
*What is your date of birth?
An error exists
*What is your gender?
Male
Female
Other
What is your occupation?
Employed
Government
Homemaker
Retired
Student living with Parents
Student not living with Parents
Unemployed
Military
Retail
Sales
Marketing
IT
Medical
Unknown
Business Owner
Student
Sales Inside
Sales Outside
Scientist
Other Technical
Military enlisted
Architect
Other
What is your marital status?
Married
Divorced
Separated
Single
Widowed
What is your education level?
Bachelors Degree
Master Degree
Doctorate Degree
High School Diploma
Some College
Associate Degree
Other
None
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*Who is the Applicant?
Myself
Spouse
Child
Sibling
Parent
Grandparent
Grandchild
Other
Currently employed?
Yes
No
Currently student?
No
Yes
Do you have a residence in the US?
Yes
No
Height Foot
2
3
4
5
6
7
8
Height Inch
0
1
2
3
4
5
6
7
8
9
10
11
Weight in lbs
An error exists
BMI
An error exists
Household income in USD
below 30000
> 30000
> 45000
> 60000
> 75000
> 100000
People in household
An error exists
Previously denied insurance?
No
Yes
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Prescriptions
*Do you have any prescriptions?
No
Yes
Description of prescriptions
An error exists
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Medical History
*Hospitalized before?
No
Yes
*You have ongoing medical treatments?
No
Yes
Are you smoker?
No
Yes
Are you alcohol abstain?
No
Yes
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Conditions
*Do you have any pre existing conditions?
No
Yes
High Cholesterol
No
Yes
Ulcers
No
Yes
Vascular Disease
No
Yes
AIDS / HIV
No
Yes
Arthritis
No
Yes
Asthma
No
Yes
Kidney Disease
No
Yes
Cancer
No
Yes
HighasdDepressionfsadf
No
Yes
Diabetes
No
Yes
Heart Disease
No
Yes
Liver Disease
No
Yes
Plumonary Disease
No
Yes
Hepatitis
No
Yes
High Blood Pressure
No
Yes
Mental Illness
No
Yes
Stroke
No
Yes
Alzheimer
No
Yes
Alcohol Abuse
No
Yes
Drug Abuse
No
Yes
Other
No
Yes
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Policy Current
*Are you currently insured?
No
Yes
Current Insurance Company
Company not listed
21st Century
AAA
AARP
AIG
Access Insurance
AETNA
AFLAC
AIU
Alfa Insurance
All Risk
Allianz
Allied
Allstate
American Alliance Insurance
American Family
American Home Assurance
American Insurance
American International Insurance
American International Pacific
American Internacional south
AMS User Group
American International South
American Direct Business Insurance
American Deposit Insurance
American Casualty
American Manufacturers
American Empire Insurance
American Financial
American Health Underwriters
American Mayflower Insurance
American Motorists Insurance
American National
American Premier Insurance
American Protection Insurance
American Automobile Insurance
American Reliable
American Republic
American Savers Plan
American Service Insurance
American Skyline Insurance Company
American Spirit Insurance
American Standard Insurance
AmeriPlan
Ameriprise
Amica
Answer Financial
Anthem
Arbella
Armed Forces Insurance
Associated Indemnity
Assurant
Atlanta Casualty
Atlantic Indemnity
Atlantis
Auto Club Insurance Company
AXA Advisors
Auto Owners
Bankers Life and Casualty
Banner Life
Best Agency USA
Blue Cross / Blue Shield
Brooke Insurance
Commonwealth
Company not listed
Cal Farm Insurance
California State Automobile Association
Chubb
Cigna
Citizens
Clarendon
Clarendon National Insurance
CNA
Colonial Insurance
Comparison Market
Continental Insurance
Cotton States
Country Insurance and Financial Services
County Insurance and Financial Services
Countrywide
Countywide
CSE Insurance Group
Dairyland Insurance
eFinancial
eHealth Insurance Sercies
eHealthInsurance Services
Electric Insurance
Elephant
Equitable Life & Casualty Insurance
Erie Insurance
Esurance
Farm Bureau/Farm Family/Rural
Farmers
FinanceBox.com
Fire and Casualty Insurance Co of CT
Farmers Union
Fidelity Insurance Company
Fidelity National
Fireman's Fund
Foremost
Foresters
Geico
AMSUserGroup
Garden State Life Insurance Company
GMAC
Golden Rule Insurance
Government Employees Insurance
Government Empoyees Insurance
Grange
Great American
Great West
Guaranty National Insurance
Guide One Insurance
Hanover Lloyd's Insurance Company
The Hartford
Guardian
Guideone
Hartford AARP
Health Benefits Direct
Health Care Solutions
Health Choice One
Health Net
Health Plus of America
HealthMarkets
HealthShare American
Horace Mann
Horace Mann Insurance
Humana
IFA Auto Insurance
IGF Insurance
IDS
IHIAA
Infinity Insurance
Insurance Insight
Infinity National Insurance
Infinity Select Insurance
Insphere Insurance Solutions
Insurance Shopper, Inc
Insurance.com
Integon
Iroquois Group
John Hancock
Kaiser Permanente
Kemper Lloyds Insurance
Landmark American Insurance
Leader Insurance
Leader Preferred Insurance
Leader Specialty Insurance
Liberty Insurance Corp
Liberty Mutual
Liberty National
Liberty Northwest
Liberty Nothwest
Lincoln Benefit Life
Lumbermens Mutual
Maryland Casualty
Mass Mutual
Mega/Midwest
Matrix Direct
Mercury
MetLife Auto and Home
Metropolitan Insurance Co.
Mid Century Insurance
Continent Casualty
Middlesex Insurance
Midland National Life
Mutual Insurance
National Insurance
Miller Mutual
Modern Woodmen of America
Mutual of New York
Mutual Of Omaha
National Ben Franklin Insurance
National Casualty
Continental Casualty
Continental Divide Insurance
National Continental Insurance
National Fire Insurance
National Health Insurance
National Indemnity
National Union Fire Insurance
Nationwide
New England Financial
New York Life Insurance
Northwestern Mutual Life
Nortwestern Mutual Life
Norhwestern Pacific Indemnity
Northwestern Pacific Indemnity
Omni Insurance
Orion Insurance
Pacific Insurance
Pafco General Insurance
Patriot General Insurance
Peak Property and Casualty Insurance
PEMCO Insurance
Physicians
Penn Mutual
Pennsylvania life
Premier
Primerica
Principal Financial
Progressive
Protective Life
Prudential Insurance Co.
RBC Liberty
Reliance Insurance
Republic Indemnity
Response Insurance
SAFECO
Safeway Insurance
Security Insurance
Senior Market Sales
Sentinel Insurance
Sentry
Shelter
St. Paul Insurance
Standard File Insurance Company
Standard Fire Insurance Company
State and County Mutual Fire Insurance
State Farm
State National
Superior American Insurance
Superior Guaranty Insurance
Superior Insurance
Sure Health Plans
The Ahbe Group
The General
TICO Insurance
TICO Insurance1
TIG Countrywide Insurance
Titan
TransAmerica
Travelers
State Consumer Insurance
Twin City Fire Insurance
UniCare
United Insurance
United American/Farm and Ranch
United Life Group
United Pacific Insurance
United Security
United Services Automobile Association
Unitrin Direct
Universal Underwriters Insurance
US Financial
US Health Group
USA Benefits / Continental General
USA Benefits/Continental General
USAA
USF and G
Viking Insurance
Western and Southern Life
Western Mutual
William Penn
Windsor Insurance
Woodlands Financial Group
Zurich North America
Other
Insured since
An error exists
Insurance end
An error exists
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*First Name
*Last Name
*Phone number
*Email
*ZIP
*Street Address
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