• Medicare Insurance Plan ENROLLMENT QUESTIONS - leave fields blank that are not applicable or put NA

    This form is Needed to submit an enrollment application for Medicare Supplement, Medicare Advantage and/or Prescription Drug Coverage (enrollment will not be transmitted for either without your final verbal consent, this makes the enrollment process much quicker).
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  • 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.

    Part D or Medicare Advantage plans do not need to be canceled because Medicare will do it automatically upon approval of the new plan.

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