Medicare Supplement Quote Form Applicant Information (required) First Name: Mr. Mrs. Ms. Last Name: Age:     Tobacco: Yes No Spouse Information First Name: Last Name: Age:     Tobacco: Yes No Contact Information Street: Apt/box number City: State: Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDist. ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNY Non-BusNY BusinessNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingGuamPuerto RicoVirgin IslandsAmerican Samoa Zip Code: County: Daytime Phone: Evening Phone: E-mail: Comments or Critical Information Have existing coverage? Yes No With whom? How soon should coverage begin?