Part I - Applicant Information
Part II - Medical & General questions - Please give details to "yes". Include insured or spouse name.
C. Are you covered for medical assistance through the state Medicaid program:
D. Are you covered or will you be covered under:
Health Questions (Answer for all Insureds)
Within the past two (2) years for (a) through (e) have you had, or had a medical diagnosis of:
The below questions are not required of applicants applying for this coverage within 6 months of obtaining Medicare Part B, or under guaranteed issue status.
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