DAVEVIC..employee benefits, group hospitalization insurance, pension plans and commercial insurance.

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Beyond the Obvious"

1- 800-854-4099
724-458-7255
Fax: 724-458-7261
service@davevic.com

902 South Center Street
P.O. Box 976
Grove City PA 16127

Content copyright 2008

Please use this form to submit a quote request.
A licensed representative from our company will contact you about your request.

Medicare Supplement Quote
First Name
Last Name
Birthday (mm/dd/yyyy)
Gender	Male Female
Street
City
State
Zip Code
Telephone*
Medicare Part A & B Information Please check all that you are currently enrolled in	Medicare Part A Medicare Part B
Effective Dates Please list effective dates for Part A & B. (Can be found on Medicare card)	Effective Date Part A Effective Date Part B
Existing Supplement
Do you have an existing policy in force?	Yes No
If yes, please list your current plan
Prescription Drug Information
Do you have existing prescription drug coverage?	Yes No
If yes, please list your current plan
I currently receive benefits through:	Veterans Association TRICARE Federal Employee Health Benefits Program Other Not Applicable
I currently receive benefits through:	PACE PACENET
Any known medical conditions or regular medications?
Agent Information
Name
Telephone	(555-555-5555)
EMail

Declaration: I confirm all the statements and particulars given above are
true and that I have disclosed all the facts relating to myself.

Maintained by: Keffer Development Services