NJ Medicare Supplement Insurance Quote

We are your local northern New Jersey insurance agency, offering affordable Medicare
supplement insurance policy premiums to residents in the following cities and
counties: Succasunna, Boonton, Boonton Township, Brookside, Budd Lake, Butler,
Cedar Knolls, Chatham, Chester, Convent Station, Denville, Dover, Dover Annex, East
Hanover, Fayson Lakes, Flanders, Florham Park, Gillette, Green Village, Greystone
Park, Hibernia, High Crest, Ironia, Kenvil, Kinnelon, Lake Hiawatha, Lake Hopatcong,
Lake Intervale, Landing, Ledgewood, Lincoln Park, Lindy Lake, Long Valley, Lower
Montville, Lyonsville, Madison, Mendham, Meriden, Millington, Mine Hill, Montville,
Montville Township, Morris Plains, Morristown, Mount Arlington, Mount Freedom, Mount
Olive, Mount Tabor, Mountain Lakes, Netcong, New Vernon, Parsippany, Pequannock,
Pequannock Township, Picatinny Arsenal, Pine Brook, Pinebrook, Pompton Junction,
Pompton Plains, Powerville, Ralston, Randolph, Riverdale, Rockaway, Rockaway
Valley, Schooleys Mountain, Stirling, Tabor, Taylortown, Towaco, Troy Hills, Wharton,
Whippany, Stanhope, Hopatcong, Espanong, Hurdtown, Cranberry Lake, Andover,
Greendell, Woodport, Springdale, Oak Ridge, Milton, Sparta, Lake Lenape, Newton,
Ogdensburg, Saxton Falls, Johnsonburg, Allamuchy, Vienna, Hackettstown,
Beattystown, Marksboro, Hope, Townsbury, Washington, Newark, 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, Somerset, Milltown, South River,
Bound Brook, Somerville, Bridgewater, 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,
Morris County, Sussex County, Somerset County, Pasaic County, Bergen County,
Hunterdon County, Union County, and Warren County, NJ. We also offer Medicare
supplement insurance services throughout the state of New Jersey, including the
greater New York City area.

Full Name:
Home Address:
City:
State: (New Jersey or New York)
Zip Code:
Email Address: (Required)
Home Phone: Work Phone: Ext.
How to Contact You:
Date of Birth:             (mm/dd/yyyy)
Gender:    Height: ft.
Weight:    Do you smoke?

Are you a U.S. citizen?

  Current Medicare Information
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)

Questions for New Jersey Medicare Supplement Insurance Quote
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:    Condition:

Medication Name: Dosage:
Frequency:    Condition:

Medication Name: Dosage:
Frequency:    Condition:

Spouse Information & Health Questions

Is Spouse to be insured?
Spouse: Full Name:
Spouse Date of Birth: (mm/dd/yyyy)
Spouse Gender:
Is spouse a U.S. citizen?

  Spouse Current Medicare Information
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)

Questions for New Jersey Medicare Supplement Insurance Quote (Spouse)
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:    Condition:

Medication Name: Dosage:
Frequency:    Condition:

Medication Name: Dosage:
Frequency:    Condition:

Additional Information or Comments

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

**Information received from this New Jersey Medicare Supplement Insurance quote request form sent to Your Life Solutions, 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 New Jersey Medicare Supplement 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 New Jersey Medicare Supplement Insurance Policy. We are licensed in New Jersey, New York, and will not provide quotes for other states.