Personalized Medicare Supplement Quote

Part I Contact Information (all fields marked with an * must be filled in to continue)

First Name *

Last Name *

Email Address *

Phone Number

use format xxx -xxx-xxxx

Best Time to Call

Street Address *

Apt. #

City *

State

Zip*

Part II Plan Information

Which of these three statements most accurately describes the characteristics of a health insurance plan that appeals to you? (select one)

I am not too concerned about everyday medical expenses, but I want very good coverage for catastrophic losses. (lowest cost plans)

I would like very good coverage for services such as doctor visits, emergencies and prescriptions, but I would accept a higher deductible for inpatient services in return for a more affordable premium.
(mid-range plans)

I want a plan with very comprehensive coverage for inpatient and outpatient services, with very little out-of-pocket costs. (highest cost plans)

Information about you and your family.
List Spouse only if inquiring about rates for Him/Her

Relationship	Date of Birth or Age	Sex	HT?	WT?	Smoker?
		M F
		M F

Would you like to receive e-mail on new products or services we offer?

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Questions/Comments

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WORLDWIDE INSURANCE SERVICES, INC. All Rights Reserved © 2005-2007
237 Melvin Drive
Northbrook, IL 60062
Phone: 800-955-0418 Fax 847-559-9499
Alan A Leafman, Agent state of domicile and principal place of business IL -CA lic# OB98320