Medicare Quote Step 1 of 520%Name* First Last Email* Phone*Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Where do you get your health coverage now?Employer Group PlanHealthcare.govMedicaidI don't have insuranceOtherWhat health insurance company?Other:Do you have a spouse/dependents on your health plan? Yes NoAre you currenly enrolled in Medicare Part A or B? Yes NoWhat was the effective date?Do you have a preference of: Medicare Advantage Medigap/Medicare Supp No PreferenceAre you currently employed? Yes NoApprox how many employees work at your employer?Do you smoke or use tobacco? No YesDo you have end stage renal disease? No YesDo you travel extensively? No YesPlease list any medications you're taking and the dosageWhat is most important to you in healthcare Doctor Network accessibility Saving Money Travel Extra benefits OtherWhat else is important to you?Are there extra benefits you'd like to include Hearing Aids Fitness Membership Eye Care Dental OtherWhat other benefits would you like to include?If you have a primary care physician or see specialists for an issue - what are the names of the doctors and the practice/hospital where they work?
