Tell us about your medical insurance Check if you have Medicare Part A Medicare Claim #:_______________________________ Insurance other than Medicare, if any: Company name: Insurance for You Policy number: ________________________________ Group number: ________________________________ Check off all the services that are covered: Hospital Doctor/Surgical Dental Prescription Vision/Optical Long Term Care Policy start date: Stop date: Policy premium amount: $________ per _____________ Date you started paying this premium: _______________
or Part B . Check if your spouse has Medicare Part A
or Part B .
Insurance for Your Spouse
Medicare Claim #:______________________________ Insurance other than Medicare, if any: Company name: ______________________________ Policy number: _______________________________ Group number: ______________________________ Check off all the services that are covered: Hospital Doctor/Surgical Dental Prescription Vision/Optical Long Term Care Policy start date: Stop date: Policy premium amount: $_______ per ___________ Date you started paying this premium: ____________
Tell us about your income List all income that you and your spouse receive. List the amounts of income before any deductions are made. Examples of income are: Social Security, Supplemental Security Income (SSI), wages, pensions, disability benefits, worker’s compensation, unemployment compensation, interest, dividends, rental property income, alimony, and child support. Income for Yourself Income for Your Spouse Where does the money come from? How much do you receive? How often do Where does the money come from? How much do you receive?
How often do you receive it? (hourly, weekly, every other week, monthly, yearly)
you receive it? (hourly, weekly, every other week, monthly, yearly)
Wages (employer name):
Wages (employer name):
$
$
Interest:
Interest:
$
$
Social Security (type):
Social Security type):
$
$
Pension (company name):
Pension (company name):
$
$
IRA (name of bank):
IRA (name of bank):
$
$
Other (describe):
Other (describe):
$
$
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