L & J Insurance - Florida Health Insurance Agency

Medicare Supplement Quote Form

Full Name:

Mailing Address:

City:

State: ** Florida Residents Only. We currently only market and service Medicare Supplements in Florida.

Zip:

Daytime: Evening: Phone:
No agents will call for appointment but required if any verification of information is necessary.

E-mail:

Fax Number:

Sex: Male Female

Height: Weight:

Date of Birth:

Please Indicate Level of Tobacco Usage?NeverNone Last 12 MonthsNone Last 5 Years

Marital Status? Single Married

Is your spouse to be insured? Yes No

Spouse's name:
Spouse's Gender: Male Female

Spouse Height: Weight:

Spouse's Date of Birth:

Please Indicate Spouse's Level of Tobacco Usage?NeverNone Last 12 MonthsNone Last 5 Years

In the past 24 months has any applicant or dependent (if to be insured) been advised or taken a prescription drug for more than 14 days? If yes please provide full details below (name, dosage, frequency)      YesNo

Have you or any dependents to be insured ever been treated for, been advised by a physician that they have or may have had any one of the following; Heart Condition (Including Murmur), Stroke, High Blood Pressure, Diabetes, Cancer, Tumor, Cyst, Liver, Kidney Disorder, any Disease or disorder of the Reproductive System, Seizures, Or Nervous System Disorders, Asthma Allergies or other Respiratory Disorders, Alcohol or Drug Abuse Dependence, Pyschological, Physciatric Disorder.        YesNo

Any surgery in the last 2 years? Yes No

Any in-patient hospital stays in the last 5 years? Yes No

Are you Retired? Yes No

Do you maintain residences in more than one state? Yes No

Do You Qualify for Medicare because of a disability? Yes No

Which products would you also like more information on? (Check All That Apply)
Long Term Care
Home Health Care
Do you have any of the following? (Check All That Apply)
Long Term Care
Home Health Care
Medicare Supplements
If you have medicare supplements, please indicate the carrier:
Which of the ten standardized medicare supplement plans do you currently carry?

Additional Comments



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