Medicare Supplemental Insurance Quotes for PA and DE

We are your local Allentown, PA area insurance agency, offering affordable
Medicare supplemental insurance policy quotes and services in the following
Pennsylvania cities and counties: Philadelphia County, Delaware County,
Montgomery County, Chester County, Bucks County, Lehigh County, Berks
County, Lancaster County, York County, Emmanus, Hellertown, Whitehall,
Cetronia, East Texas, Lanark, Dorneyville, Wagnersville, Catasauqua,
Walbert, Farmersville, Stiles, Friedensville, Mechanicsville, Hanover, North
Catasauqua, Stroudsburg, King of Prussia, Springfield, Woodlyn, Chester,
Norwood, Ridley Park, Prospect Park, Folcroft, Darby, Swarthmore, Drexel
Hill, Rutledge, Yeadon, Upper Darby, Secane, Milmont Park, Garden City,
Wallingford, Morton, Aldan, Primos, Pilgrim Gardens, Colwyn, Lester,
Essington, Eddystone, Landsdowne, Fernwood, Milbourne, Havertown,
Broomall, Penn Wynne, Merion Station, Wynnewood, Haverford, Penn Valley,
Bala-Cynwyd, Ardmore, Rosemont, Overbrook, Belmont Hills, Villanova,
Rebel Hill, Gulph Mills, Gladwyne, Conshohocken, Kings Manor, Swedeland,
Swedesburg, Bridgeport, Norristown, Lafayette Hill, Plymouth Meeting,
Erdenheim, Oreland, Flourtown, Ardsley, North Hills, West Conshohocken,
La Mott, Cheltenham, Melrose Park, Elkins Park, Glenside, Wyncote, Roslyn,
Abington, Huntingdon Valley, Rydal, Meadowbrook, Jenkintown, Hollywood,
Rockledge, Somerton, Bustleton, Torresdale, Holmesburg, Tacony,
Kensington, Feltonville, Frankford, Olney, Andalusia, Cornwells Heights,
Bridgewater, Croydon, Bensalem, Nottingham, Bristol, Edgely, Newportville,
West Bristol, Strafford, Devon, Berwyn, Port Kennedy, Newtown Square,
Gradyville, Cheyney, Concordville, Narberth, Milltown, Westtown, Trainer,
Marcus Hook, West Chester, Lancaster, York, Reading, Bethlehem,
Pottstown, Coatesville, Kulpsville, Warminster, Montgomeryville, Levittown,
Valley Forge, Malvern, Green Tree, Paoli, Devault, Chatwood, Goshenville,
Sugartown, Glenloch, Chester Springs, Audubon, Eagleville, Evansburg,
Worcester, Blue Bell, Center Square, Fort Washington, Philadelphia,
Doylestown, Chalfort, Quakertown, Perkasie, Sellersville, Soudertown, Willow
Grove, Warrington, Morrisville, Ambler, Lower Gwynedd, Washington
Crossing, New Hope, Richboro, Feasterville, Southampton, Langhorne,
Holland, Newtown, and Yardley, PA.

Full Name:
Home Address:
City:     State:     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)

Current Medicare Information
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)

Health Questions for Medicare Supplemental Insurance Quote
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:

Spouse Information
                                         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)

Spouse Current Medicare Information
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)

Spouse Health Questions for Medicare Supplemental Insurance Quote
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
Pennsylvania or New Jersey Medicare supplemental insurance quote request.**