Palffy Insurance Group

Medicare Supplement Quote Request

Medicare Supplement Quote Form
*Required Fields

First Name*

Last Name*

Phone Number*

Email Address*

Zip Code*

Plan(s) to Quote:
(Select up to four plans to compare prices)

Date of Birth*


Tobacco Use*

Are you new to Medicare?

Did you recently turn 65 or will you turn 65 in the near future?

Will you be losing or did you recently lose employer group insurance?

If you answered "yes" to any of the above questions, don't fill out the health questions that follow. We have enough information to process your quote request. Please click "Submit" and we'll start working on your quote.

If you answered "no" to all three of the questions, please fill out the following health information before submitting this form so that we can process your quote.



Do you have a family physician?

List any medical conditions for which you are currently being treated:

List any medical conditions that you recovered from in the past five years (please include dates):

List all medications that you are currently taking (include daily dosage amounts):

Additional Comments:

A sales agent may call you as a result of submitting this form. We may need to clarify some information while completing your quote request. We may call you to discuss your options after you receive your quote.

The information you provide will only be used to satisfy your quote request. Certain information will be shared with insurance companies for quoting purposes only. No insurance company and no other insurance agency will market to you as a result of submitting this form. We do not share your information with outside organizations for marketing purposes.

Medicare Supplement Plans

Medicare Supplements help pay for expenses that Medicare Parts A & B don't cover, like deductibles, coinsurance and copayments. Medicare Supplements are also known as "Medigap" policies because they help "fill in the gaps" in coverage of Original Medicare.

Medicare Supplements are sold by private insurance companies, but the policies are standardized and regulated by the federal government. The plans vary in what they cover, so you could pick a plan that covers some of the deductibles, coinsurance and copayments, or you could pick a plan that covers all of them. Some Medicare Supplements cover expenses that Medicare doesn't cover at all.

When you have a Medicare Supplement, Medicare pays its portion of the medical bills first. Then, the Medicare Supplement pays its share of the bills. You're responsible for whatever is left over (if anything).

Medicare Supplements don't work with Medicare Advantage plans. In fact, it's illegal for an agent to sell you a Medicare Supplement if you have a Medicare Advantage plan. You should either have Original Medicare plus a supplement OR a Medicare Advantage plan. Remember, Medicare Advantage plans are an alternative way to get your Part A and Part B benefits. Medicare Supplements, on the other hand, are designed to work in tandem with Original Medicare.