Welcome To EZMedicarePlans.com Quote Page Where only one agent will contact you with multiple quotes.. Beware of other quote submission companies who sale your information to multple agents. We will NEVER sale your information period!

You are Guaranteed to get Multiple Quotes from well-known and strong financially rated companies that offer plans in your area. Your information is secure and will never be sold to any other agent.

By completing this form you are allowing EZMedicarePlans.com to determine which plans are available in your area and which plans will provide you the best benefit for the least amount of money. You can be assured the most accurate plan that meets your needs.  You may also call us at 1-888-896-7797 with questions.

Primary Applicant to be Quoted
Primary First Name	*
Primary Middle
Primary Last Name	*
Primary Applicant Date of Birth	*
Primary - Do You Use Tobacco?	*	Please Select One Yes No I recently stopped using
Primary Applicant Height	*
Primary Applicant Weight	*
Primary Applicant-Do You Have Medicare ?	*	Please Select One Applicant has both Part A and B Applicant has part A only Applicant has part B only Applicant recently applied for part B Applicant does not have either part A or part B
Is Primary Applicant Receiving Financial Assistance on Medicare Part B Premium?	*	Please Select One Yes No Not Sure
Name of Current Insurer on Primary Applicant
Medicare Health Plan Products to Quote for Primary	*	Please Select One Quote Me Medicare Supplemental Plans Available in My State Contact Me About Medicare Advantage and Medicare Supplement Plans in My Sate Plan A Only Plan B Only Plan C Only Plan D Only Plan E Only Plan F Only Plan G Only Plan H Only Plan I Only Plan J ONly Chronic Illness Plan Only * Not a Medicare Supplement I'm Not Sure
A Physical Residental Address is desired in order to determine the availability of Medicare Plans that you may qualify for which is based upon where you live. If you have a PO BOX that is not in the county you live in then your quote may not be accurate.
Address 1	*
Address 2
City	*
State	*	- - Choose One - - Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code	*
COUNTY of Residence	*
The next question is asked in order to dermine if you or a spouse is eligible for a special enrollment period.
Some Individuals who are losing group coverage due to layoff, job loss etc may be eligable for a special enrollment perod which allows you to join a new plan with a gauranteed acceptance regardless of health. This is the reason for the next question.
Have You or a Spouse lost group coverage?		Please Select One Yes No
Are You New To this Area?	*	Please Select One I have just moved to the area (Less than 3 months) I have lived here 4 months or more I have lived here 6 months or more I have lived here for 1 or more years
Are You Including a Spouse In this Quote?	*	Please Select One Yes No No Spouse In the future Spouse Already on a plan
Spouse Applicant To Be Quoted
Spouse First Name
Spouse Middle
Spouse Last Name
Spouse Date of Birth
Spouse Height
Spouse Weight
Spouse - Do You Use Tobacco?		Please Select One Yes No Recently stopped using
Spouse - Do You Have Medicare?		Please Select One Spouse has Part A and Part B Spouse has only Part A Spouse has only Part B Spouse has Part A and recently applied for Part B Not Sure
Is Spouse Receiving Financial Assistance on Part B Medicare premium?		Please Select One Yes No Not Sure
Name of Current Insurer on Spouse (if applies)
Spouse Medicare Health Plan Products to Quote Spouse		Please Select One Quote Me Medicare Supplemental Plans Available in My State Contact Me About Medicare Advantage and Medicare Supplement Plans in My Sate Plan A Only Plan B Only Plan C Only Plan D Only Plan E Only Plan F Only Plan G Only Plan H Only Plan I Only Plan J ONly Chronic Illness Plan Only * Not a Medicare Supplement I'm Not Sure
Medicaid or Income State Assistance?	*	Please Select One No I am receiving Medicaid or Low Income Assistance Spouse is receiving Medicaid or Low Income Assistance Both I and my Spouse are receiving Medicaid or Low Income Assistance.
Some individuals may be eligable to enroll in special needs plans due to their chronic conditions. This is the reason for the next question. You may answer these questions if you would ike for us to determine if you are eligable for special needs plan. These plans are county specific and may not be available in your county. Please select all the conditions that your doctor can verify.
Do You or a Spouse Have a Chronic Illness Listed? Please Select		COPD : Asthma: Chronic bronchitis Emphysema Cardiac Arrhythmia Chronic Heart Failure Coronary Artery Disease Hypertension (High Blood Pressure) Peripheral Vascular Disease Endocrine Metabolic: Diabetes Neurologic Disorders: Dementia Immune Disorders Rheumatoid Arthritis
Who Has The Chronic Illnesses You Selected?		Please Select One Primary Applicant Only Spouse Only Both Primary and Spouse
Prescription Drug Plans		Please Select One Please Contact Me About Medicare Prescription Drug Plans Please Contact Me About Prescription Drug Discount Plans Not Interested In Prescription Drug Plans
Does Primary Applicant Currently Have A Prescription Drug Plan?	*	Please Select One Yes No Yes But losing coverage not sure
Does Spouse (If applies) Currently Have A Prescription Drug Plan?		Please Select One Yes No Yes but losing coverage Not sure
Please List Primary Applicants -Prescriptions
Please List Spouse' Prescriptions
Dental Plans		Please Select One Please include a "stand alone" dental plan in my area for consideration. No Not Interested In Dental Plans
Do You Need A Life Insurance Quote?		Please Select One Term Insurance Whole Life Universal Life Final Expense Other Not Interested at this time
Desired Amount of Life Insurance
Vision Insurance that pays for routine check ups and hardware such as glasses and contacts are sometimes included in Medicare Advantage plans but are usually not covered items under a Medicare Supplement policy so if you would ike a quote that includes a "stand alone" Vision Insurance plan then simply answer the next question.
Vision Insurance Plans		Please Include with Quote Not Interested
Do You Want A Long Term Care Insurance Quote?		Please Select One Yes - Primary Applicant Yes- Spouse Only Yes - Primary and Spouse No Not Interested at this time.
Email Address	*
Confirm Email Address	*
Phone Number with area code	*
Fax Number with area code (Optional)
Desired Method of Contact		Please Choose One Please Call and Speak to me about the various plans (only one agent will call) Please contact me by email Please Fax Me the Quote Please US Mail Me the Quote It doesn't matter to me
Desired Effective Date	*
Best Time To Contact You		- - Choose One - - 8:00 AM 9:00 AM 10:00 AM 11:00 AM 12:00 PM 1:00 PM 2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00 PM 11:00 PM 12:00 AM 1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM
Security Code	*