[Questions]

If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare supplement insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplement plans. Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS.

[Please mark Yes or No below with an “X”]

To the best of your knowledge,

1. a. Did you turn age 65 in the last 6 months?

Yes ______ No _______

b. Did you enroll in Medicare Part B in the last 6 months?

Yes ______ No _______

c. If yes, what is the effective date?

___________________________

2. Are you covered for medical assistance through the state Medicaid program?

Yes ______ No _______

[NOTE TO APPLICANT: If you are participating in a “Spend-Down Program” and have not met your “Share of Cost,” please answer NO to this question.]

If yes,

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]?