Medicare Supplement Application
Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Social Security Number
*
Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Examples- Custer, Canadian, Logan. (Counties)
Date of Birth
*
City you were born
*
State you were born
*
Height
Feet
Height
Inches
Weight
Pounds
Medicare Number
Ex: 4PD4-BT6-TD36 FOUND ON YOUR RED, WHITE, AND BLUE CARD.
Do you have Medicare Part A?
Please Select
Yes
No
IF you have Medicare Part A, what is the date coverage started?
Found on your red, white, and blue card.
Do you have Medicare Part B?
Please Select
Yes
No
IF you have Medicare Part B, what is the date coverage started?
Found on your red, white, and blue card.
Are you covered for medical assistance through the state Medicaid program?
Please Select
Yes
No
If you are participating in a Spend-Down Program and have not met your Share of Cost, please answer "No" to this question.
Do you have another Medicare supplement or Medicare Select insurance policy or certificate in force?
Please Select
Yes
No
Have you had coverage from any Medicare plan other than Medicare Part A or B within the past 63 days?
Please Select
Yes
No
For example, a Medicare Advantage plan, or a Medicare HMO or PPO.
Have you had coverage under any other health insurance within the past 63 days?
Please Select
Yes
No
For example, an employer group health plan, union plan, or individual non-Medicare supplement plan.
Who was your last health insurance with?
What was the policy number?
The name of the pharmacy you use and the city its located in.
Name(s) of all the prescription drugs you take, along with the dosage, and how many times a day you take it.
EXAMPLE: Lisinopril, 12.5mg, 2 times daily or as needed
Do you want to add dental to your policy? $61.42/ Month (You will receive a 15% discount at the time of enrollment) if you add a dental policy within 30 days of your initial enrollment... Making it $52.21 monthly.
*
Yes
No
Banking Information
Name of Bank
Routing Number
Account Number
I agree all my answers are true.
*
Yes
No
Signature
Upload a picture of your Medicare card
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Upload a picture of your drivers license
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