Medicare Supplement (Medigap) Quote | Seguro Advisory Group

1

Your information

Required

First name *

Last name *

Address 1 *

Address 2 (optional)

City *

State *

ZIP code *

Date of birth *

Cell phone *

Home phone *

Email address *

2

Coverage preferences

Optional, but helpful

Retirement date

Do you currently have group coverage?

YesNo

Do you currently have Medicare?

YesNo

Monthly budget

3

Health history

Optional. Have you had any of the following medical conditions?

Medicare Supplement Quote Information Disclaimer

The information provided on this form is being collected solely for the purpose of evaluating Medicare Supplement insurance options and preparing a quote. Providing this information does not constitute an application for insurance, guarantee eligibility, or guarantee coverage or rates.

By submitting this information, you authorize Seguro Advisory Group and its licensed insurance representatives to contact you regarding Medicare Supplement insurance options and related insurance products. Your information may be used to obtain quotes and evaluate available coverage options with applicable insurance companies and will be handled in accordance with applicable privacy and insurance requirements.

Rates, eligibility, underwriting requirements, coverage amounts, policy features, and availability may vary by insurance company, state, age, health history, and other applicable factors. Final rates, coverage, and policy terms are subject to the insurance company's underwriting guidelines and approval.

Important: Please do not provide your Social Security number, Medicare Beneficiary Identifier (MBI), bank account information, credit card information, or other highly sensitive financial information on this form unless specifically requested through a secure application process.

I understand that submitting this form is a request for information and/or a Medicare Supplement insurance quote and is not an application for insurance. I consent to being contacted by Seguro Advisory Group and its licensed insurance representatives regarding Medicare Supplement insurance options and related insurance products.

Medicare Supplement (Medigap)

Medicare Supplement Information & Needs Assessment

Your information

Coverage preferences

Health history

Medicare Supplement Quote Information Disclaimer

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