Medicare Supplement Application

Name

First NameMiddle NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Social Security Number

Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is your mailing address different than your physical?

Mailing Address

Street Address

Street Address Line 2

CityState / 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?

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?

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?

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?

Have you had coverage from any Medicare plan other than Medicare Part A or B within the past 63 days?

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?

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.

Name of Bank

Routing Number

Account Number

What day would you like your supplement to be drafted each month?

The applicants' first payment for their Medicare supplement policy will be withdrawn from their bank account on the date their policy is approved.

I agree all my answers are true.

Upload a picture of your Medicare card

You can text me a picture if that is easier.

Upload a picture of your drivers license

You can text me a picture if that is easier.

Signature

Medicare Supplement Application

Banking Information