Erie Insurance Medicare Supplement Quote Form

Name: ALLCHOICE Insurance
Price range: $

ALLCHOICE Agent Information
Select Your Advisor*
INSURED INFORMATION
Proposed Insured*
First Middle Last
(EXACTLY HOW IT IS LISTED ON MEDICARE CARD)
Phone
Date Of Birth
MM slash DD slash YYYY
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Gender
- Female
- Male
Have You Used Tobacco In The Past 12 Months
- No
- Yes
Height
Weight
POLICY INFORMATION & MEDICARE INFORMATION
Effective Date
MM slash DD slash YYYY

On What Date Would You Like Coverage To Begin
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Choose Your Medicare Supplement Plan
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Are You Covered Under Medicare Part A
- Yes
- No
(If there is a Part A date on your Medicare ID card please answer Yes. If you do not have a card or there is no Part A date on the card please answer No)
Medicare Part A Eligibility | Effective Date (MM/DD/YYYY)
(If you do not have a Medicare ID card please enter the date you will become eligible)
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Did you enroll in Medicare Part B in the last 6 months?
- Yes
- No
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Have you enrolled in Medicare Part B more than once?
- Yes
- No
Medicare Part B Eligibility | Effective Date (MM/DD/YYYY)
(If you do not have a Medicare ID card please enter the date you will become eligible)
Medicare Number (Do Not Include Dashes)
(IF YOU DO NOT HAVE YOUR MEDICARE ID NUMBER YET, PLEASE ENTER ‘UNKNOWN')
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Social Security Number
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Do You Qualify For Guaranteed Issue?
- Yes
- No
- I Am Not Sure
(If unsure or not familiar with guaranteed issue please select the response "I am not sure")
Application will be signed in what State?
State
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GUARANTEE ISSUE QUESTIONS
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Which of the following most accurately represents your situation?
- The individual is enrolled under an employee welfare benefit plan that either supplements Medicare, and the plan terminates, or the plan ceases to provide all such benefits; or is primary to Medicare and the plan terminates or the plan ceases to provide all such supplemental health benefits to the individual. a. Underage 65 applicants that lose coverage under a managed care plan, either voluntarily or involuntarily is guaranteed issue. A group employer plan is considered a managed care plan. b. Age 65 and older where a spouse who is the primary insured on a group employer plan cancels the other spouse, the spouse that lost coverage is GI due to a involuntary termination.
- Enrolled in a Medicare Advantage plan or is 65 years of age or older and enrolled in Program of All-Inclusive Care for the Elderly (PACE) and the organization’s certification or plan is terminated or specific circumstances permit discontinuance including, but not limited to, a change in residence of the individual, the plan is terminated within a residence area, the organization, agent, or other entity acting on the organization’s behalf substantially violated a material provision of the organization’s contract, or a material misrepresentation was made to the individual.
- Enrolled in a Medicare risk contract, health care prepayment plan, Medicare cost contract or Medicare Select plan, or similar organization, and the organization’s certification or plan is terminated or specific circumstances permit discontinuance including, but not limited to, a change in residence of the individual, the plan is terminated within a residence area, the organization, agent, or other entity acting on the organization’s behalf substantially violated a material policy/certificate provision of the organization’s contract, or a material misrepresentation was made to the individual.
- Enrolled in a Medicare Supplement policy/certificate and coverage discontinues due to insolvency, bankruptcy or other involuntary termination of coverage or enrollment under the policy, substantial violation of a material policy/certificate provision, or material misrepresentation.
- Enrolled under a Medicare Supplement policy/certificate, terminates and enrolls for the first time in a Medicare Advantage plan, a risk or cost contract, or a Medicare Select plan, a PACE provider, and then the insured person terminates coverage within 12 months of enrollment.NOTE: You must return to your previous Medicare Supplement insurer AND plan you had in force before joining your current Medicare Advantage plan, risk or cost contract, Medicare Select or PACE plan. If your previous plan is not available you may qualify for Guaranteed Issue with Erie Family Life Insurance Company.
- Upon first becoming eligible for benefits under Medicare, enrolls in a Medicare Advantage or PACE provider and then disenrolls from the plan or program within 12 months.
- None of the above apply, I do not qualify for Guaranteed Issue.
PREMIUM DISCOUNT INFORMATION
You may be eligible for a policy with a lower premium rate based on your answers to the questions in this section.
Do you reside in a condominium unit, a single family home, or an apartment unit within an apartment complex?
- Yes
- No
Do you reside in the same household with your spouse, civil union partner or a permanent resident who is over the age of 18 and has continuously resided with you for a minimum of 12 months?
- Yes
- No
Name
First Last
Age
Date Of Birth (MM/DD/YYYY)
Residence Address Same As Mailing Address Entered Above?
- Yes
- No
Address
Street Address City State ZIP Code
Relationship To Applicant
Do you currently have a Home, Auto or Life Insurance policy with Erie Insurance?
- Yes
- No
Existing Auto Policy Number?
Existing Home Owner's Policy Number?
Existing Life Insurance Policy Number?
HEALTH & MEDICAL (PART 1)
IF YOU ANSWER YES TO THE FOLLOWING QUESTIONS, YOU ARE NOT ELIGIBLE FOR COVERAGE.
Are you currently confined to a wheelchair or use any motorized mobility device?
- Yes
- No
Are you currently hospitalized, confined to a bed, in a nursing home or assisted living facility?
- Yes
- No
Are you currently receiving or been advised to have any occupational, speech or physical therapy?
- Yes
- No
Have you been advised by a medical professional to have treatment, further diagnostic evaluation, diagnostic testing, follow up visits or any surgery that has not been performed?
- Yes
- No
Have you had any medication administered in a physician’s office via injection, infusion or IV in the past 24 months or are any scheduled or anticipated in the next 12 months?
- Yes
- No
At any time have you been medically diagnosed with, treated for or had surgery for any of the following? Chronic kidney disease, kidney failure or kidney disease requiring dialysis?
- Yes
- No
At any time have you been medically diagnosed with, treated for or had surgery for any of the following? Emphysema, Chronic Obstructive Pulmonary Disease (COPD), any other chronic pulmonary disorder or any cardio-pulmonary disorder requiring oxygen?
- Yes
- No
At any time have you been medically diagnosed with, treated for or had surgery for any of the following? Alzheimer’s disease, dementia or any other cognitive disorder?
- Yes
- No
At any time have you been medically diagnosed with, treated for or had surgery for any of the following? Parkinson’s disease, multiple sclerosis or amyotrophic lateral sclerosis (Lou Gehrig’s disease)?
- Yes
- No
At any time have you been medically diagnosed with, treated for or had surgery for any of the following? Systemic Lupus, scleroderma or myasthenia gravis?
- Yes
- No
At any time have you been medically diagnosed with, treated for or had surgery for any of the following? Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?
- Yes
- No
At any time have you been medically diagnosed with, treated for or had surgery for any of the following? An organ transplant or been advised to have an organ transplant (excluding corneal transplants)?
- Yes
- No
At any time have you been medically diagnosed with, treated for or had surgery for any of the following? Chronic hepatitis or cirrhosis?
- Yes
- No
At any time have you been medically diagnosed with, treated for or had surgery for any of the following? Osteoporosis with fractures?
- Yes
- No
Have you been medically diagnosed with or treated for diabetes, or have you taken or been advised by a member of the medical profession to take prescription medication(s) to control your blood sugar in addition to any of the following: peripheral artery disease, peripheral venous thrombotic disease, any heart disorder, kidney disease, stroke or transient ischemic attack (TIA)?
- Yes
- No
Do you have an implanted cardiac defibrillator?
- Yes
- No
In the past two years, have you been treated for or been advised by a physician to have treatment for: Cardiomyopathy, congestive heart failure, aortic or cardiac aneurysm, vascular angioplasty, endarterectomy, any heart or heart valve disorder/disease or implantation of a pacemaker?
- Yes
- No
In the past two years, have you been treated for or been advised by a physician to have treatment for: Alcoholism or drug abuse?
- Yes
- No
In the past two years, have you been treated for or been advised by a physician to have treatment for: Internal cancer, lymphoma or melanoma?
- Yes
- No
In the past two years, have you been treated for or been advised by a physician to have treatment for: A heart attack, stroke or transient ischemic attack (TIA)?
- Yes
- No
In the past two years, have you been treated for or been advised by a physician to have treatment for: Spinal stenosis, psoriatic arthritis, arthritis that restricts mobility or have you been advised to have a joint replacement?
- Yes
- No
Have you been advised by a medical professional that surgery may be required within the next 12 months including cataract surgery?
- Yes
- No
Have you been hospital confined three or more times in the past two years?
- Yes
- No
HEALTH & MEDICAL (PART 2)
IF YOU ANSWER YES TO ANY QUESTION IN THIS SECTION, YOU MAY BE ELIGIBLE FOR COVERAGE.
Have you been medically diagnosed with or treated for diabetes or have you taken or been advised by a member of the medical profession to take prescription medications(s) to control your blood sugar in addition to any of the following: diabetes with retinopathy, diabetes with neuropathy or diabetes with high blood pressure?
- Yes
- No
In the past two years, have you been treated for or been advised by a physician to have treatment for: Coronary artery disease, angina, cardiac angioplasty, bypass surgery or stent placement?
- Yes
- No
In the past two years, have you been treated for or been advised by a physician to have treatment for: Peripheral artery disease, peripheral venous thrombotic disease, carotid artery disease, atrial fibrillation or other heart rhythm disorder?
- Yes
- No
In the past two years, have you been treated for or been advised by a physician to have treatment for: Any mental or nervous disorder requiring treatment (including hospital confinement) by a psychiatrist, psychologist, counselor or therapist?
- Yes
- No
In the past two years, have you been treated for or been advised by a physician to have treatment for: Degenerative bone disease or rheumatoid arthritis?
- Yes
- No
Are you currently taking or have you taken any prescription drugs or over-the-counter medications within the past 24 months?
- Yes
- No
Medication Information
Include the following information for EACH 1. Medication Name (copy off pharmacy label) 2. Date Originally Prescribed or Taken 3. Dosage 4. Frequency 5. Diagnosis And/Or Condition
REPLACEMENT INFORMATION
Are you covered for medical assistance through the state Medicaid program? (If you are participating in a “Spend-Down” program and have not met your “Share of the Cost,” please answer NO to this question).
- Yes
- No
Will Medicaid pay your premiums for this Medicare Supplement policy?
- Yes
- No
Do you receive any benefits from Medicaid OTHER THAN payment toward your Medicare Part B premium?
- Yes
- No
On what date will your current coverage end?
MM slash DD slash YYYY
What is the local Medicaid office phone number?
If known, what is your Medicaid case worker name?
Have you had coverage from any Medicare plan other than original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO)?
- Yes
- No
Name of Company?
Telephone Number
Plan Type?
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare Supplement policy?
- Yes
- No
Planned date of termination/ disenrollment?
MM slash DD slash YYYY
Was this your first time in this type of Medicare plan?
- Yes
- No
Did you drop a Medicare supplement policy to enroll in the Medicare plan?
- Yes
- No
REASON FOR REPLACEMENT - The replacement policy is being purchased for the following reason (check one):
- Disenrollment from a Medicare Advantage plan. Please explain below the reason for disenrollment
- Other, please explain below
Please Explain
Do you have another Medicare supplement policy in force?
- Yes
- No
If yes, do you intend to replace your current Medicare supplement policy with this policy?
- Yes
- No
Indicate planned termination/disenrollment date
MM slash DD slash YYYY
Name of Company?
Phone
Policy or Certificate Number
Issue Date
MM slash DD slash YYYY
Plan Type
- A
- B
- C
- D
- E
- F
- F - High Deductible
- G
- G - High Deductible
- H
- I
- J
- J - High Deductible
- K
- L
- M
- N
- PreStandard
- Other
The replacement policy is being purchased for the following reason (check one)
- Additional Benefits
- No change in benefits, but lower premiums
- Fewer benefits and lower premiums
- Change in benefits (Gaining additional benefit(s) but losing some existing benefit(s))
- My plan has outpatient drug coverage and I am enrolling in Part D
- Other, please explain below
Please Explain
Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union, or individual plan)
- Yes
- No
Name Of Company
Plan Type
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Policy / Certificate Number
(If you don't have or don't know your policy number please enter "Unknown")
Company Phone Number
PAYMENT INFORMATION
Billing Mode
- Annual
- Semi-Annual
- Quarterly
- Monthly (Must Be EFT)
Initial Bank Draft Timing
- Issue Date
- Effective Date
Subsequent Bank Draft Timing
- 1st Of The Month
- 3rd Of The Month
- 2nd Wednesday Of The Month
- 3rd Wednesday Of The Month
- 4th Wednesday Of The Month
- Other
Specified Draft Date
Must be no later than the 28th of the month
Name On Bank Account
Name Of Financial Institution
Account Type
- Checking
- Savings
Bank Routing Number
Bank Account Number
I Am An Authorized Signed On This Account
- Yes
- No

ALLCHOICE Insurance
81 Broadway St Suite 201-031
Asheville, NC 28801
828.277.5432

ALLCHOICE Insurance
2513 Neudorf Rd
Clemmons, NC 27012
336.360.8870

Heasley Insurance Services LLC
236 Tamworth Dr.
Denton, NC 27239
888.400.2608

ALLCHOICE Insurance
7 Corporate Center Ct Ste B
Greensboro, NC 27408
336.540.0463

ALLCHOICE Insurance
419 Short St
Hendersonville, NC 28739
828.237.2327

ALLCHOICE Insurance
2018 Eastwood Rd
Wilmington, NC 28403
910.500.6116

ALLCHOICE Insurance
401 Olive St
Winston-Salem, NC 27103
336.765.1971

Erie Insurance Medicare Supplement Quote Form

ALLCHOICE Agent Information

INSURED INFORMATION

POLICY INFORMATION & MEDICARE INFORMATION

GUARANTEE ISSUE QUESTIONS

PREMIUM DISCOUNT INFORMATION

HEALTH & MEDICAL (PART 1)

HEALTH & MEDICAL (PART 2)

REPLACEMENT INFORMATION

PAYMENT INFORMATION