INDIVIDUAL MEDICARE SUPPLEMENT


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Medicare Supplement

We can help you protect yourself and your family from the bills Medicare won’t pay. Although Medicare pays some of your doctor and hospital bills, it was never meant to cover all of them. If you rely on Medicare alone to pay all your bills, this can be a financially devastating year should you become hospitalized or need extensive outpatient treatment.

There are many plans available to help you fill in the gaps that Medicare leaves you to pay.

Please complete the information below and submit it to us by either email or fax and we will reply promptly to your request. You can not submit an inquiry without supplying the information highlighted with an asterisk (*).

 
Please answer the following questions:
Do you currently have another Medicare Supplement policy or certificate in force:* Yes No
If so, name of carrier:
Which plan:
Do you currently have any health insurance policies that provide some duplicate benefits:* Yes No
Name:*
Phone #:*
Date of Birth:* (MM/DD/YYYY)
Sex:* Male Female
Your Zip Code:* (5 digits)
State:
Will Your Spouse be Insured:* Yes No
Spouse's Date of Birth:* (MM/DD/YYYY)


Or print out form and fax to: (847) 866-7414
DISCLAIMER: FINANCIAL AND MEDICAL UNDERWRITING DECISIONS ARE THE DIRECT RESPONSIBILITY OF THE INSURANCE CARRIER. BDM Combined, Inc. ASSUMES NO LIABILITY FOR SUCH UNDERWRITING DECISIONS.

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BDM Combined, Inc.
Buffalo Grove, IL 60089
(847) 478-5101 Fax (866) 354-7414
info@bdmcombined.com