American Senior
Citizens Association

Turning 65? Over 65?
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Medicare Supplement Pre-Application

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YES. I understand I am under NO OBLIGATION after completing and submitting this Medicare Supplement Application foaar processing.

Section 1 - Company, Plan, and Premium Information
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Section 2 - Applicant Information
Are you completing this insurance application for yourself?* Yes No If you are completing this application on behalf of a friend or relative, please be advised that the applicant must be present to answer the following questions within this application to obtain coverage.
First Name* MI Last Name*
Residence Address* City* State* Zip Code* Phone* Phone Type Mailing Address (if different from residence address) E-mail* Confirm E-mail* Gender* Tobacco User*
Height Height and Weight not required if age within 6 months before or after 65th Birthday. Weight Date of Birth* Format: MM/DD/YYYY Date of birth is not formatted properly.

Section 1 - Applicant B Information
First Name* MI Last Name*
Residence Address* City* State* Zip Code* Phone* Phone Type Mailing Address (if different from residence address) E-mail* Confirm E-mail* Gender* Tobacco User*
Height Weight Height and Weight not required if age within 6 months before or after 65th Birthday. Date of Birth* Format: MM/DD/YYYY Date of birth is not formatted properly.
Section 3 - Household Discount

Do you live in the same household with your spouse, partner, friend or relative?* What is their DOB?* Format: MM/DD/YYYY Date of birth is not formatted properly. Relationship?* What is their first name?*
If you have any questions or need help completing the E-App, please contact us at 800-290-7535. CLICK HERE TO BOOK AN APPOINTMENT TO GET A FREE MEDICARE BENEFITS REVIEW

*Required Information

T65, 1/1/2020

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American Senior Citizens Association (ASCA)

Non-Profit Organization Since 1980

MedicareDirectQuote.org

ASCA National Administrative Office:

PO Box 41 Fayetteville, NC 28302

ASCA National Processing Center:

110 Turnberry Way, Pinehurst, NC 28374

Terms & Conditions

An Official American Senior Citizens Association Website

BUILDING A BETTER QUALITY OF LIFE FOR SENIOR AMERICANS SINCE 1980

American Senior Citizens Association (ASCA) is a non-profit organization chartered in Washington DC in 1980. ASCA's mission is to build a better quality of life through education, information, and service. The collective strength of our membership enables us to serve the broader community, improving the quality of life for all seniors. Any person age 50 and over is eligible to join. There are no membership dues. ASCA does not endorse any Medicare Plan. Royalty fees are paid to ASCA from the leading Medicare companies in America for the use of its intellectual property. These fees are used for the general purposes of ASCA.

ASCA provides an online resource for Medicare, Medicare plans, Social Security, Taxes, Discounts, Lifestyle, and Senior benefits to make life easier. ASCA also offers health insurance information, along with competitive quotes from some of the nation's leading insurance companies. Rates shown are provided as a public service and not intended as an endorsement of any company. The information contained herein is to be used for information purposes only. Nothing contained herein constitutes an application for insurance with any specific insurance company. Final rates can only be confirmed by a licensed agent approved by the appropriate insurance company.

ASCA Medicare Advisors are licensed agents and can provide complete information on Medicare plans, prescription drug plans, dental plans, final expense plans, and long-term care insurance. ASCA Certified Medicare Advisors have helped thousands of people new to Medicare with their transition into Medicare each year.

ASCA's mission is to help individuals by offering the best available quotes at affordable prices. By using this site and submitting your online quote request, you agree to give ASCA, or its affiliates, your express consent to communications with you via emails, text messages, and phone calls at the email address and phone numbers provided, including your wireless phone for the purpose of all federal and state telemarketing DO-NOT-CALL laws. Your consent to receive communications in this way is not required as a condition of purchasing any goods or services. By using this site, you acknowledge that you have read and agree to the Terms and Conditions and Privacy Policy.

Not connected with or endorsed by the United States government or the federal Medicare program.