Health/Other Information Are you covered under Medicare? Part A Yes   No Part B Yes   No If 'No', when will you become eligible: mm/dd/yyyy Have you enrolled in Medicare Part B? Yes   No If 'Yes', indicate date you enrolled: mm/dd/yyyy If 'No', indicate date you plan to enroll: mm/dd/yyyy What type of plans are you most interested in seeing?: (see sample benefits below) A B C D E F G H I J Economy Plan (C) Average Plan (F) Premium Plan (J) Basic Benefits Skilled Nursing Coinsurance Part A Deductible Part B Deductible Foreign Travel Emergency Same Same Same Same Same Same Part B Excess 100% Same Same Same Same Same Same Same At Home Recovery Extended Drugs ($3000 limit) Preventive Care

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