Medicare Supplement Underwriting Questionnaire

MEDICAL HISTORY4 questions

Heart & Circulation

Select one answer for each question below.

7. In the past two years, have you been diagnosed with, treated for, or advised to receive treatment for a heart attack, coronary artery disease, angina, atrial fibrillation, irregular heartbeat, cardiomyopathy, enlarged heart, stroke, TIA, carotid or peripheral vascular disease, or blocked arteries?

No Yes

8. In the past two years, have you had or been advised to have bypass surgery, angioplasty, stent placement, heart valve surgery or pacemaker treatment?

No Yes

9. In the past five years, have you been diagnosed with or treated for heart failure, pulmonary heart disease, ventricular tachycardia, or a condition requiring an implanted defibrillator?

No Yes

10. Have you ever had an unrepaired aneurysm or heart disease requiring a permanent implantable cardiac defibrillator?

No Yes

MEDICAL HISTORY5 questions

Diabetes & Kidneys

Select one answer for each question below.

11. Do you have diabetes with neuropathy, retinopathy, kidney problems, protein in the urine or circulation/vascular problems?

No Yes

12. In the past six months, have you needed more than 50 units of insulin per day, or had diabetes with high blood pressure requiring three or more blood pressure medicines?

No Yes

13. Have you ever had chronic kidney disease, renal insufficiency, renal failure or end-stage renal disease?

No Yes

14. Have you ever required dialysis or been advised that you may or will need dialysis?

No Yes

15. In the past two years, have you received medical treatment or advice for a kidney problem other than kidney stones?

No Yes

MEDICAL HISTORY3 questions

Cancer

Select one answer for each question below.

16. In the past three years, have you been diagnosed with, treated for, or advised about cancer (other than certain non-melanoma skin cancers)?

No Yes

17. In the past five years, have you been diagnosed with or treated for leukemia, lymphoma or multiple myeloma?

No Yes

18. In the past three years, have you been diagnosed with or treated for malignant melanoma or metastatic Merkel cell carcinoma?

No Yes

MEDICAL HISTORY4 questions

Lungs & Breathing

Select one answer for each question below.

19. Have you ever been diagnosed with or treated for COPD, emphysema, chronic bronchitis, cystic fibrosis, or a chronic respiratory disease requiring permanent oxygen?

No Yes

20. In the past two years, have you had a lung or breathing condition requiring oxygen, a nebulizer or three or more medicines?

No Yes

21. Do you currently use tobacco products and have a lung or respiratory condition?

No Yes

22. In the past two years, have you received IV infusions or injections for asthma?

No Yes

MEDICAL HISTORY5 questions

Neurological Conditions

Select one answer for each question below.

23. Have you been diagnosed with or treated for Alzheimer’s disease, dementia, Parkinson’s disease or an organic brain disorder?

No Yes

24. Have you ever been treated for multiple sclerosis, ALS, muscular dystrophy or cerebral palsy?

No Yes

25. Have you been diagnosed with paralysis, quadriplegia, paraplegia or hemiplegia?

No Yes

26. In the past two years, have you been treated for seizures?

No Yes

27. In the past two years, have you received IV infusions or injections for migraines or cognitive impairment?

No Yes

MEDICAL HISTORY5 questions

Arthritis, Autoimmune & Bones

Select one answer for each question below.

28. Have you been diagnosed with or treated for rheumatoid or psoriatic arthritis, disabling arthritis or Paget’s disease?

No Yes

29. Have you been diagnosed with or treated for lupus or myasthenia gravis?

No Yes

30. Have you had osteoporosis involving fractures or requiring injections?

No Yes

31. In the past two years, have you been diagnosed with or treated for spinal stenosis?

No Yes

32. In the past two years, have you received IV infusions or injections for autoimmune disease, osteoarthritis or a connective-tissue disorder?

No Yes

MEDICAL HISTORY6 questions

Liver, Blood & Immune System

Select one answer for each question below.

33. Have you been diagnosed with or treated for cirrhosis, liver fibrosis, liver failure, hepatitis other than A, or another liver disease?

No Yes

34. In the past two years, have you been treated for pancreatitis?

No Yes

35. Have you ever had hemophilia or another significant blood disorder?

No Yes

36. In the past two years, have you received repeated blood transfusions for anemia?

No Yes

37. In the past two years, have you had skin grafts, blood transfusions, or IV infusions/injections for a blood, immune, genetic or hereditary disorder?

No Yes

38. In the past two years, have you received IV infusions or injections for primary immunodeficiency syndrome?

No Yes

MEDICAL HISTORY3 questions

Mental Health & Substance Use

Select one answer for each question below.

39. Have you ever been diagnosed with or treated for bipolar disorder, schizophrenia or a paranoid disorder?

No Yes

40. Have you been treated for severe depression or received prescription medication for depression for two or more years?

No Yes

41. In the past two years, have you had treatment or counseling for alcohol or drug abuse?

No Yes

MEDICAL HISTORY7 questions

Other Conditions & Treatments

Select one answer for each question below.

42. Have you had, or been advised you need, an organ, bone marrow or stem-cell transplant (other than a corneal transplant)?

No Yes

43. Have you had an amputation caused by disease?

No Yes

44. Have you been diagnosed with wet macular degeneration, or received IV infusions/injections for an eye disorder within the past two years?

No Yes

45. Have you ever tested positive for HIV or been diagnosed with AIDS or an AIDS-related condition?

No Yes

46. Have you been treated for Addison’s disease?

No Yes

47. Have you had a PSA level greater than 6.0?

No Yes

48. Do you currently use tobacco/nicotine products and have heart disease, vascular disease or diabetes?

No Yes

MEDICAL HISTORY4 questions

Pending Tests & Procedures

Select one answer for each question below.

49. Has a medical professional recommended surgery, a biopsy, diagnostic testing or further evaluation that has not been completed (excluding routine screenings where permitted by the insurer)?

No Yes

50. Are you awaiting diagnostic test results?

No Yes

51. Have you been advised to undergo medical treatment or therapy that has not yet been completed?

No Yes

52. Is surgery anticipated or already scheduled?

No Yes

MEDICAL HISTORY2 questions

Medications & Treatment Changes

Select one answer for each question below.

53. Within the past two years, have you taken prescription medicines for any of the conditions mentioned above?

No Yes

54. Within the past two years, have you had a change in cardiovascular medication or an increase in dose for a heart or vascular condition?

No Yes

FINAL STEPContact details

Almost done — where can we reach you?

Your information helps a Plan Medicare advisor follow up about your Medicare Supplement options.

Full name Email Phone number State of residence

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Your Medical Underwriting Questionnaire

Hospitalizations & Daily Care

Heart & Circulation

Diabetes & Kidneys

Cancer

Lungs & Breathing

Neurological Conditions

Arthritis, Autoimmune & Bones

Liver, Blood & Immune System

Mental Health & Substance Use

Other Conditions & Treatments

Pending Tests & Procedures

Medications & Treatment Changes

Almost done — where can we reach you?