ENROLLMENT QUESTIONS

ENROLLMENT QUESTIONS

Needed to submit an enrollment application for Medicare Supplement (enrollment will not be transmitted for either without your final verbal consent, this makes the enrollment process much quicker).
Name as it appears on Medicare Card

Address

Mailing address if different

Best phone number

Area Code Phone Number
Email
example@example.com
Social Security Number
DOB

Month Day Year
Date Date Picker Icon
PART B EFFECTIVE DATE

Month Day Year
Date Date Picker Icon
MEDICARE #
PART A EFFECTIVE DATE

Month Day Year
Date Date Picker Icon
Effective Date of policy Requested

Month Day Year
Date Date Picker Icon
Medicare Supplement Company Preference
Medicare Supplement Plan Letter Preference (A-N)
Anticipated Monthly Premium
Prescription Drugs taking optional but helps you price compare and choose the right Prescription plan* (include name and dosage)
Name of the Pharmacy you like to use
How would you like to pay your Part D premium?

EFT/Bank Draft (preferred) Monthly invoice & check SSA deduction
Name of Bank: For monthly premium draft (MED SUPP and/or Part D)
Routing Number
Account Number
Date of the month for reoccurring draft (first month’s premium is drafted immediately)
Current Insurance
DO NOT CANCEL ANY COVERAGE UNTIL NEW COVERAGE IS IN PLACE. I will send you guidance when the time comes.Click to edit this text..