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FORM NAME: Med Sup Guy Quote - Main

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Name (as appears on Medicare Card)

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Plan

G (most common) N High Deductible Plan G Medicare Advantage

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Part B Start

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Have you used tobacco in the past 12 months?

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Current health plan (company name and plan type)

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The person living with you is

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List ALL prescription drugs you take and include the mg, dose per day (If you take no drugs type NONE)

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