Medicare Supplement Application

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Residence ZIP Code * Application State *

Gender * Male Female

Date of Birth * Requested Effective Date *

Are you applying for Medicare Supplement Insurance? * Yes No

Are you currently covered under or are you enrolled to be covered under:

Medicare Part A? * Yes No If "Yes", Effective Date *

Medicare Part B? * Yes No If "Yes", Effective Date *

Name

First Name * MI Last Name *

Plan & Discount

Which Medicare Supplement plan are you applying for? * Plan F Plan G Plan N

7% Household Discount *

Do you wish to apply for the 7% household discount? (You'll provide the household member's information on the next page.)

Yes No

6-Month Open Enrollment

Are you eligible for coverage under the "Open Enrollment" period (the 6-month period beginning with the first month in which you are both age 65 or older and enrolled in Medicare Part B)?

Yes No

Virginia Annual Open Enrollment

Are you applying for guaranteed-issue coverage on your birthday or during the 60-day period following your birthday?

Yes No

Previous & Existing Coverage

Are you currently covered or enrolled to be covered under Social Security Disability? * Yes No

Are you currently married and residing with your spouse, or have you been living with at least one (1) but not more than three (3) persons, who are all aged 50 or over, for at least the last 12 months? * Yes No

Name Relationship

If you've lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue of a Medicare Supplement insurance policy, or that you have certain rights to buy such a policy, please give the notice to your broker so it can be submitted with your application.

To the best of your knowledge:

Did you turn age 65 in the last 6 months? * Yes No

Did you enroll in Medicare Part B in the last 6 months? * Yes No

Are you younger than age 65 and eligible for Medicare by reason of disability as defined by federal law? * Yes No

Are you eligible for Medicare under 42 USC §426-1 (end stage renal disease)? * Yes No

Are you enrolled (or expected to be enrolled) in Medicare Part A and Part B? * Yes No

If "Yes", what is the effective date of Part A? If "Yes", what is the effective date of Part B?

Are you covered for medical assistance through the state Medicaid program? *

If you are participating in a "spend-down program" and have not met your "Share of Cost," answer "No" to this question.

Yes No

If you had coverage from any Medicare plan other than Original Medicare within the last 63 days (for example, a Medicare Advantage Plan or a Medicare HMO or PPO), please indicate below. Yes No

Start Date End Date

Was this your first time in this type of Medicare plan? Yes No

Did you drop a prior Medicare Supplement plan to enroll in the Medicare plan? Yes No

Do you have another Medicare Supplement policy currently in force? * Yes No

If "Yes", with what company? Please specify If "Yes", with what plan do you have?

If "Yes", do you intend to replace your current Medicare Supplement policy with this policy for which you are applying? Yes No

If "Yes", a Replacement Form is required and you must notify your existing company. Your broker will handle this with you.

Have you had coverage under any other health plan within the last 63 days (for example, an employer, union, or individual plan)? * Yes No

Health History

Answer each question carefully. If you are unsure about an answer, leave it for now and discuss with your broker before submitting.

Tobacco

In the past 2 years, have you used any type of tobacco products or any tobacco-related products, including e-cigarettes or vaping? *

If "Yes", Standard rates must be used (except for Open Enrollment or Guaranteed Issue applicants).

Yes No

Are you currently, or at any time within the past 1 month, have you:

Been hospitalized, or required assistance to perform activities of daily living, or required the use of a walker, wheelchair, or motorized mobility aid? * Yes No

Received any occupational, speech, or physical therapy from a medical professional? * Yes No

Been confined to a bed, nursing facility, or assisted living facility, or received home health care? * Yes No

Do you currently have or at any time in the past 6 months have you:

Had an implanted cardiac defibrillator for an arrhythmia? * Yes No

Required over 50 units of insulin per day for treatment of diabetes? * Yes No

Required the use of supplemental oxygen (including for obstructive sleep apnea)? * Yes No

Had disabling arthritis or arthritis that restricts mobility? * Yes No

In the last 2 years, have you:

Had angina (chest pain due to heart disease)? * Yes No

Had hepatitis C? *

Do not answer "Yes" if you were treated successfully, no longer have hepatitis C, and do not have cirrhosis or other liver damage.

Yes No

Been treated by infusions or injections administered in a medical facility for any condition (excluding those for allergies, vitamin B12, osteoporosis, or knee pain)? * Yes No

Been advised by a medical professional to have any surgery, medical tests (excluding those for routine care), medical treatments, or do you have pending diagnostic evaluations that have not yet been completed? * Yes No

Had any part of your body amputated due to disease? * Yes No

Been hospitalized or required the services of a psychologist, psychiatrist, or counselor for depression or any other mental or nervous condition? * Yes No

Had a new onset of heart attack, stroke, or transient ischemic attack (TIA)? * Yes No

Had surgery for any heart or circulatory disease (excluding maintenance on a previously installed pacemaker, or treatment for varicose veins)? * Yes No

Had a fracture due to osteoporosis? * Yes No

In the last 2 years, have you been diagnosed with or treated by a medical professional for any of the following:

Cancers or Tumors? * Yes No

Check all that apply:

Hodgkin's disease Any internal cancer Malignant melanoma

Alcohol or drug abuse or dependency? * Yes No

Peripheral vascular disease (PVD) or peripheral arterial disease (PAD)? * Yes No

Crohn's disease or ulcerative colitis? * Yes No

Atrial fibrillation? * Yes No

Spinal stenosis? * Yes No

Within the last 10 years, have you ever had, or been diagnosed with or treated by a medical professional for diabetes with a history at any time in the past of any of the following: retinopathy affecting vision, neuropathy, nephropathy, skin ulcers, surgery for circulatory disease, heart attack, stroke or transient ischemic attack (TIA)? * Yes No Please give name of diagnosis

Within the last 10 years, have you ever had, or been diagnosed with or treated by a medical professional for:

Organ transplant or have you been advised to have an organ transplant or are you waiting to have an organ transplant (excluding corneal transplant)? * Yes No

Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), or tested positive for the Human Immunodeficiency Virus (HIV)? * Yes No

Within the last 10 years, have you ever had, or been diagnosed with or treated by a medical professional for any of the following diseases or disorders? *

Chronic kidney disease, end-stage renal (kidney) disease, kidney/renal failure or insufficiency, dialysis or been advised to have dialysis, systemic lupus, systemic scleroderma, rheumatoid arthritis, chronic hepatitis B, fibrosis of the liver, cirrhosis of the liver, muscular dystrophy, multiple sclerosis, Parkinson's disease, Lou Gehrig's disease (ALS), chronic bronchitis, chronic obstructive pulmonary disease (COPD), emphysema, any other chronic respiratory disorder (excluding asthma), cardiomyopathy, congestive heart failure (CHF), Alzheimer's disease, dementia, organic brain syndrome, bi-polar disorder, manic-depressive disorder, schizophrenia, sickle cell anemia, leukemia, myeloma, non-Hodgkin's lymphoma, any form of metastatic cancer.

Yes No Please give name of diagnosis

At any time in the last 6 months, have you been diagnosed with or treated by a medical professional for:

Diabetes with no complications, and require 50 or less units of insulin per day? * Yes No

Macular degeneration not requiring injections? * Yes No

Obstructive sleep apnea requiring a CPAP or for which a CPAP has been recommended? * Yes No

Cardiac arrhythmia requiring a pacemaker? * Yes No

Osteoporosis treated by infusion? * Yes No

Medications

List all prescription drugs you are currently taking or have been medically advised to take. If you are not taking any medications, check the box below.

I am not currently taking any medications and have not been medically advised to take any.

Physicians

Provide the name and contact information of your Primary Care Physician or any other physicians who are treating you.

I do not have a Primary Care Physician and I am not under the care or attendance of any physician(s) for the treatment of any health or medical condition.

Personal Information

Applicant Information

First Name * MI Last Name *

Date of Birth * Place of Birth (State) *

Height — feet * Height — inches * Weight (lbs) *

Social Security Number *

Confirm SSN *

Gender * Male Female

Medicare Number *

Confirm Medicare Number *

Contact Information

Email *

Preferred number to reach * Home Mobile

Home Phone Mobile Number *

Home Address

Address *

City * State * ZIP *

Residence County * Use a different mailing address

Mail policy to * Policyholder Agent / Producer

Payment & Billing

Payor is someone other than the applicant

Initial Premium Payment (Bank Draft)

Bank Name *

Account Type * Checking Savings

Routing Number * Confirm Routing Number *

Account Number * Confirm Account Number *

Payment Date for Initial Premium * Upon Approval On Effective Date Other

The initial premium will not be drafted/charged prior to underwriting approval. Payment is required on/prior to the effective date.

Recurring Premium Payment

Use same payment method as the initial premium payment

Recurring Premium Mode * Monthly Quarterly Semi-Annual Annual

Billing Method * AutoPay Mail Bill

Billing Type * Individual Family

Recurring Payment Date * Day of the month Draft Schedule Day of the month (1–28)

Funds will not be drafted on weekends or federal holidays.

Review & Submit

Please review your responses below. Use the Back button to make corrections. When you're ready, click Submit Application. Your information will be sent securely to your broker.

Acknowledgement * I certify that the information I have provided is true and complete to the best of my knowledge. I understand that my broker will contact me to review this information before submitting it to Bankers Fidelity, and that this is not the final application.