Contact Information: Your Name: Home Address: City: State: Zip: Phone #: Alternate Phone #: Date of Birth: Age: Gender: Male Female   Spouse's Name: Date of Birth: Age:   Do You Currently Have: Medicare Part A and Part B: Yes No Med Sup.: Company Name Premium: Med. Advantage: Company Name Premium: Group Coverage: Company Name Premium: Part D (Drug Plan): Company Name Premium:   (Health Survey) In the last two years, have you had a/an: Heart Attack COPD Stroke Emphysema Rheumatoid Arthritis Internal Cancer Tobacco Use Insulin Dependent Diabetes Other