Pre-Qualification - Sovereign Select Insurance

Name*

First Last

Phone

Email

Birth Date

Zip Code

Height*

Weight*

Current Medicare Supplement Plan

Current Medicare Supplement Plan Cost

Have You Been Advised By A Physician To Have Surgery, Medical Tests, Treatment Or Therapy That Has Not Been Performed?

Yes
No

Have You Been Advised By A Physician That Surgery May Be Required Within The Next 12 Months For Cataracts?

Yes
No

Have You Been Hospitalized Two Or More Times Within The Past Two Years?

Yes
No

Are You Currently Hospitalized, Bedridden, Living In A Nursing Facility, Using A Wheelchair Or A Motorized Mobility Aid?

Yes
No

Have You Had An Organ Transplant?

Yes
No

Diagnosis

Have you been diagnosed with emphysema, chronic pulmonary disorder other than asthma, Parkinson’s disease, systemic lupus, myasthenia gravis, multiple sclerosis, ALS (amyotrophic lateral sclerosis), osteoporosis with a fracture or fractures, cirrhosis, Alzheimer’s disease, senile dementia or any other cognitive disorder, Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC,) or Human Immunodeficiency Virus (HIV) infection?

Yes
No

Diagnosis

If you have been diagnosed with diabetes, have you also been diagnosed with retinopathy, diagnosed with neuropathy, diagnosed with heart disease, treated for high blood pressure with three or more medications, or advised by a medical professional to take more than 50 units of insulin daily or more than two medications (insulin or oral)?

Yes
No

Diagnosis

Within the past two years, have you been treated or been advised by a physician to have treatment for internal cancer, melanoma, alcoholism, drug abuse, mental or nervous disorder requiring psychiatric hospitalization, chronic hepatitis, chronic kidney disease, coronary artery disease, carotid artery disease, heart rhythm disorders including use of pacemaker or defibrillator, heart attack, congestive heart failure, enlarged heart, stroke, Transient Ischemic Attack (TIA,) heart valve surgery, peripheral vascular disease, rheumatoid arthritis, crippling or disabling arthritis, or amputation caused by disease?

Yes
No

Have You Used Any Tobacco Product In The Past 12 Months?*

Yes
No

Are You Taking Or Have You Taken Any Prescription Or Over-The-Counter Medications Within The Past 12 Months? If Yes, List The Medication Name, Frequency And Dosage, And Diagnosis/Condition/Reason For The Medication(s):

Supplement Review