Connecticut Medicare Supplement Insurance Quote

**Information received from this Medicare Supplement Insurance quote request form sent
to the William Malloy Insurance Agency will be for our use only and will not be sold,
given to or distributed to any other parties. A quote will be based on the Medicare
supplemental insurance policy information provided and does not guarantee acceptance
of the risk by us. The precise coverage afforded is subject to meeting underwriting
guidelines, and the terms, conditions and exclusions of the policy as issued. By
submitting this request you acknowledge that this is neither an offer to insure nor a
guarantee of insurance. Completion of this form does not entitle you to a Connecticut
Medicare Supplement Insurance policy. We are licensed in Connecticut and will not
provide quotes for other states.

We are a local Fairfield County insurance agency offering affordable Connecticut
Medicare supplement insurance policy quotes in the following cities and
counties: Stamford, Norwalk, Greenwich, Darien, Riverside, Belltown,
Springdale, Round Hill, Old Greenwich, East Norwalk, New Canaan, Glenville,
Byram, Cos Cob, Mianus, North Stamford, Glenbrook, Wilton, Weston, Long
Ridge, Noroton, West Norwalk, Westport, High Ridge, Southport, North Wilton,
Winnipauk, Cannondale, Turn of River, South Wilton, Lyons Plains, Georgetown,
Ridgefield, Branchville, Redding, Topstone, Ridgebury, Redding Ridge,
Branchville, Dodgingtown, West Redding, Titicus, Hattertown, Bethel, Danbury,
New Fairfield, Newtown, Hawleyville, Botsford, Monroe, Bridgeport, Stepney,
Shelton, Huntington, Upper Stepney, Long Hill, Trumbull, Stratford, Easton,
Fairfield, Greenfield Hill, Stratfield, Nichols, Oronoque, Rivercliff, Devon, Lordship,
and East Bridgeport, New Haven, Hartford, Torrington, Waterbury, Meriden, New
Britain, New London, Norwich, Manchester, East Hartford, Suffield, Granby,
West Haven, West Hartford, Branford, East Haven, Hamden, Woodbridge,
Orange, North Haven, Groton, Rocky Hill, Newington, Wethersfield, Glastonbury,
Bloomfield, Blue Hills, South Windsor, Naugatuck, New Hartford, Chesire, East
Lyme, Old Mystic, Wallingford, Southington, Middletown, Bristol, Laurel Beach,
Litchfield, Pleasure Beach, Mystic, North Westchester, Double Beach,
Willimantic, Storrs, Canaan, East Windsor, Vernon, South Canaan, Putnam,
Guilford, Windham, South Britain, Willington, Windsor, East Hampton, Brooklyn,
Westchester, and everywhere else in New Haven County, Litchfield County,
Middlesex County, New London County, Hartford County, Tolland County and
Windham County, CT.

In addition to Connecticut
Medicare Supplement
Insurance, we also offer
affordable Long Term Care
Insurance policy premiums
or choose another CT family
insurance coverage from the
list below.

Full Name:
Home Address:
City:     State:     Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Date of Birth:             (mm/dd/yyyy)

Are you a U.S. citizen?
Do you have an Alien Registration Receipt Card?
Card Number:
U.S. Arrival Date: (mm/dd/yyyy)

Are you covered under Medicare "Part A"?
If "No", when will you become eligible? (mm/dd/yyyy)

Are you covered under Medicare "Part B"?
If "No", when will you become eligible? (mm/dd/yyyy)

Are you covered for medical assistance through the state Medicaid program?
...as a specified low income Medicare beneficiary?
...as a qualified Medicare beneficiary?
...for other Medicaid medical benefits?

Do you have another Medicare supplement insurance
policy or certificate in force?
If "Yes", do you intend to replace the current policy or
certificate with this policy(certificate), and if so, what is
the termination date? (mm/dd/yy)

Within the last 2 years have you been aware of, diagnosed and /or been treated by a member
of the medical profession for: heart disease or disorder, stroke, cancer, drug or alcohol
dependency, mental disorder, crohn's disease or ulcerative colitis, nervous system disorder,
liver disorder, spinal disc disease, knee or hip disorders, or any amputation caused by disease?

Have you been hospitalized within the past 12 months, due to be so confined or been disabled
for more than 5 days within the past 12 months?

During the last 5 years have you been diagnosed by a member of the medical profession
as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS related complex (ARC)
or tested positive for HIV?

Do you have Parkinson's Disease or Multiple or Lateral Sclerosis?

Are you currently hospitalized or confined to a nursing facility, or are you bedridden or
confined to a wheelchair?

Have you been diagnosed with Alzheimer's Disease, senile dementia, organic brain disorder,
or any other senility disorder?

Do you have kidney disease requiring dialysis or diabetes requiring more than 50 units
of insuline daily?

Do you have emphysema, Chronic Obstructive Pulmonary Disease (COPD), or other
Chronic Pulmonary disorders?

Have you been advised to have surgery or medical tests that have not been performed?

Have you used tobacco in any form during the last 12 months?

Are you currently taking or have you taken any prescription or over-the-counter
medications during the last 12 months?

If you answered "Yes" to the question above please provide the necessary information below:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

                                         Is Spouse to be insured?
Spouse: Full Name:
Spouse Date of Birth: (mm/dd/yyyy)
Spouse Gender:
Is spouse a U.S. citizen?
Does spouse have an Alien Registration Receipt Card?
Card Number:
Spouse's U.S. Arrival Date: (mm/dd/yyyy)

Is spouse covered under Medicare "Part A"?
If "No", when will your spouse become eligible? (mm/dd/yyyy)

Is spouse covered under Medicare "Part B"?
If "No", when will your spouse become eligible? (mm/dd/yyyy)

Is spouse covered for medical assistance through the state Medicaid program?
...as a specified low income Medicare beneficiary?
...as a qualified Medicare beneficiary?
...for other Medicaid medical benefits?

Does spouse have another Medicare supplement insurance policy or certificate in force?
If "Yes", does spouse intend to replace the current policy or certificate with this policy(certificate),
and if so, what is the termination date? (mm/dd/yyyy)

Within the last 2 years has your spouse been aware of, diagnosed and /or been treated by a member
of the medical profession for: heart disease or disorder, stroke, cancer, drug or alcohol
dependency, mental disorder, crohn's disease or ulcerative colitis, nervous system disorder,
liver disorder, spinal disc disease, knee or hip disorders, or any amputation caused by disease?

Has spouse been hospitalized within the past 12 months, due to be so confined or been disabled
for more than 5 days within the past 12 months?

During the last 5 years has spouse been diagnosed by a member of the medical profession
as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS related complex (ARC)
or tested positive for HIV?

Does spouse have Parkinson's Disease or Multiple or Lateral Sclerosis?

Is spouse currently hospitalized or confined to a nursing facility, or bedridden or
confined to a wheelchair?

Has spouse been diagnosed with Alzheimer's Disease, senile dementia, organic brain disorder,
or any other senility disorder?

Does spouse have kidney disease requiring dialysis or diabetes requiring more than 50 units
of insuline daily?

Does spouse have emphysema, Chronic Obstructive Pulmonary Disease (COPD), or other
Chronic Pulmonary disorders?

Has spouse been advised to have surgery or medical tests that have not been performed?

Has spouse used tobacco in any form during the last 12 months?

Is spouse currently taking or has taken any prescription or over-the-counter
medications during the last 12 months?

If the answer was "Yes" to the question above please provide the necessary information below:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Medication Name: Dosage: Frequency:
Reason/Condition:

Additional Information or Comments

Click on the "Submit Quote Information" button below to send
your Connecticut Medicare supplement insurance quote request.**

Applicant Information