SK ASSOCIATES
292 East Dorrance Street
Kingston, PA 18704-5231
Phone: (570) 718-0260
Toll Free: (800) 314-9706
Fax: (570) 718-0261
Websites:
www.pagrouphealth.net
www.pamedicareinsurance.com
Request a quote for Medicare Supplement
About You
Your First Name*
Your Last Name*
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PA
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Your Health Insurance Information
Do you currently have Health Insurance?*
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If "yes", when does your current policy expire?
If "yes", who are you currently insured with?
Are you a*
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What is your Birth Date (mm/dd/yyyy)*
Type of Medicare Plan:
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Medicare Plan D Drug Coverage
Medicare Supplement
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Are you eligible for open enrollment?
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Is your coverage ending because?
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Moving Service Area
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Have you been confined to a hospital within the last 2 years?
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In the last 6 months have you been treated for a heart disorder or skin cancer?
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Are you waiting or confined to the hospital, nursing home, or been discharged in the last 10 days?
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Have you been advised to have surgery or procedure and not done so?
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Are you currently covered under medicare parts A or B?
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Optional coverage (check the ones you may want)
Life Insurance
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