EZMedicare Form1

This Is A Secure Form by EZMedicareplans.com a domain registered to Gary Hunt Insurance.. Your Information Is Never Sold and Only One Agent Will Contact You. Keep Your Privacy Private. Start Your Quote Request Today!

Gender

Male Female

Month of birth

Day of birth

Year of birth

Height - Feet

Height Inches

Weight - Lbs

Smoker?

Yes No

Currently have insurance?

No - No current coverage Yes -Group Plan Yes -Medicare Supplement plan Yes- Medicare Advantage plan Yes-But losing coverage soon

Do You Need A Prescription Drug Plan?

Yes No I'm not sure

Medical Conditions?

No Major Medical Conditions	HIV/Aids	End Stage Renal Desease	Arthritis
COPD (chronic obstructive pulmonary disease)	Heart Attack	Stroke	Diabetes
High Blood Pressure	Depression (requiring medication)	Cancer	Pregnant

Are You Including a spouse in this quote?

Yes No

If You Are NOT Including A Spouse In This Quote Then Please Skip Spouse Questions and Go to "LAST STEP" at the bottom of form.

Gender of Spouse

Male Female

Spouse Month of Birth

Spouse Day of birth

Spouse year of birth

Spouse Height - Feet

Spouse Height - Inches

Spouse Weight - Lbs

Smoker?

Yes No

Spouse - Currently have insurance?

No - No current coverage Yes -Group Plan Yes -Medicare Supplement plan Yes- Medicare Advantage plan Yes-But losing coverage soon

Spouse - Do You Need A Prescription Drug Plan?

Yes No I'm Not Sure

Spouse - Medical Conditions?

No Major Medical Conditions	HIV/Aids	End Stage Renal Desease	Arthritis
COPD (chronic obstructive pulmonary disease)	Heart Attack	Stroke	Diabetes
High Blood Pressure	Depression (requiring medication)	Cancer	Pregnant

LAST STEP *** LAST STEP *** LAST STEP *** LAST STEP *** LAST STEP Please enter the contact information below and desired effective date then Sumbit Form.

First Name

Last Name

City

Address

State

Zip Code

Area Code and phone number (xxx) -xxx-xxxx

Municipal or County

Email Address

Confirm Email

Desired Effective Date of Coverage

Disclaimer - We appreciate you taking the time to complete this form. We understand that you are searching for answers to your Medicare options and we seek to provide to you the absolute best rates in your state. Sometimes there can be errors in your rate because not all insurance companies use the same method of rate calculation and if this is so in your case then we kindly appologize. We wil do everything in our power to provide the most accurate quotes. We do not promise you insurance as only an insurance company can provide coverage. We are simply a tool to help you find the best solution to your specific problem. Remember, your information will never be sold and we promise it will remain confidential at all times. By submitting this form you agree that you have read and understood the terms of this quote request.