New Jersey Medicare Supplement Insurance Quote

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

**Information received from this New Jersey Medicare Supplement Insurance quote

request form sent to American Insurance Services 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 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 New Jersey Medicare Supplement Insurance policy. We are licensed in New Jersey

and will not provide quotes for other states.

"Your Local New Jersey Medicare Supplement Insurance Specialist!"

We offer affordable Medicare Supplement insurance policy premiums to residents of the

following New Jersey counties and cities: Union County, Essex County, Bergen

County, Passaic County, Sussex County, Morris County, Warren County,

Hunterdon County, Somerset County, Middlesex County, Monmouth County,

Mercer County, Burlington County, Clark, Newark, Jersey City, Elizabeth, Rahway,

Colonia, Iselin, Avenel, Woodbridge, Port Reading, Carteret, Perth Amboy, Fords,

South Amboy, Metuchen, Plainfield, Dunellen, South Plainfield, Green Brook,

Fanwood, North Plainfield, Cranford, Scotch Plains, Westfield, Union, Millburn,

Springfield, Mountainside, Gillette, Warren, Watchung, Stirling, Millington,

Middlesex, Martinsville, Piscataway, Edison, New Brunswick, Highland Park, North

Brunswick, Sayreville, East Brunswick, Somerset, Milltown, South River, Bound

Brook, Somerville, Bridgewater, Bayonne, Linden, Roselle, Hoboken, Union City,

Weehawken, West New York, Guttenberg, Cliffside Park, Edgewater, North Bergen,

Secaucus, Fairview, Ridgefield, Fort Lee, Leonia, Palisades Park, Englewood Cliffs,

Englewood, Bergenfield, Teaneck, Paramus, Bogota, Ridgefield Park, Little Ferry,

Hackensack, Maywood, Teterboro, South Hackensack, Rochelle Park, Moonache,

Lodi, Hasbrouck Heights, Saddle Brook, Garfield, Elmwood Park, Woodridge,

Carlstadt, East Rutherford, Lyndhurst, Rutherford, Wallington, Passaic, Clifton,

Paterson, Totowa, West Paterson, Little Falls, Great Notch, North Caldwell, Cedar

Grove, Verona, Montclair, Bloomfield, West Orange, Glen Ridge, Belleville, Nutley,

Kingsland, North Arlington, Kearney, Harrison, East Orange, East Newark, Orange,

Irvington, South Orange, Hillside, Townley, Livingston, Wayne, Trenton, Camden,

Atlantic City, Princeton, Vineland, Willingboro, and Toms River, NJ.

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 New Jersey Medicare supplement insurance quote request.**

Applicant Information

Current Medicare Information

Health Questions for Medicare Supplement Insurance Quote

Spouse Information

Spouse Current Medicare Information

Spouse Health Questions for Medicare Supplement Insurance Quote