a. Will Medicaid pay your premiums for this Medicare supplement policy?

Yes _____ No _______

b. Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?

Yes ______ No ______

3. a. If 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 health maintenance organization or preferred provider organization), fill in your start and end dates below. If you are still covered under this plan, leave “END” blank.

START ___/___/___ END ___/___/___

b. 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 ______

c. Was this your first time in this type of Medicare plan?

Yes _____ No ____

d. Did you drop a Medicare supplement policy to enroll in the Medicare plan?

Yes _____ No _____

4. a. Do you have another Medicare supplement policy in force?

Yes _____ No _____

b. If so, with what company, and what plan do you have [optional for Direct Mailers]?

______________________________________________

c. If so, do you intend to replace your current Medicare supplement policy with this policy?

Yes ______ No ______

5. Have you had coverage under any other health insurance within the past 63 days? (For example an employer, union, or individual plan)

Yes _____ No ______

a. If so, with what company and what kind of policy?

________________________________________________

b. What are your dates of coverage under the other policy?

START ___/___/___ END ___/___/____

(If you are still covered under the other policy, leave “END” blank.)

Ins 3.39(23)(b)(b) Agents shall list, in a supplementary form signed by the agent and submitted to the issuer with each application for Medicare supplement coverage, any other health insurance policies they have sold to the applicant as follows: