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Enter the following information to see the Medicare Supplement plans available in your area. All fields are required.

Enter zip code or county Required

Error: Zip Code is required.

Date of Birth: (format: mm/dd/yyyy) Date of Birth is blank.

Gender:

Male Female Please select gender for the Primary Applicant

Do any of the following apply to you? If so, you may be eligible for a Guaranteed Issue Rate.

Turned age 65 and enrolled in Medicare Part B in the last 6 months OR you will turn age 65 and enroll in Medicare Part B within the next 6 months, on or before the effective date you selected for this plan to start.

You enrolled in a Medicare Advantage plan right when you turned 65 but have changed your mind in the last year.

Are losing coverage from a Medicare Advantage plan (like an HMO or PPO) because your plan is leaving Medicare or stops giving care in your area, or you move out of the plans’ service area.

Have original Medicare and an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays and that plan is ending.

Have Original Medicare and a Medicare SELECT policy. You are moving or have moved out of the Medicare SELECT policy’s service area.

Joined a Medicare Advantage Plan or Programs of All-Inclusive Care for the Elderly (PACE) when you were first eligible for Medicare Part A at 65, and within the first year of joining, you decided you want to switch to Original Medicare.

Dropped a Medicare Supplement policy to join a Medicare Advantage Plan (or to switch to a Medicare SELECT policy) for the first time; you have been in the plan less than a year, and you want to switch back.

Your Medicare Supplement insurance company has gone or is going bankrupt and you lost or are losing your coverage, or your Medicare Supplement policy otherwise has ended or is ending through no fault of your own.

Are leaving a Medicare Advantage Plan or are dropping a Medicare Supplement policy because the company has not followed the rules, or it misled you.

Yes No Guaranteed Issue Rate is required.

Used Tobacco in the past: Refers to any usage of tobacco (e.g. cigarettes, cigars, pipes, snuff, or chewing tobacco) in the past 12 months.

Are you a Tobacco user?

Yes No Please provide a valid response

Requested Effective Date:

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