Medicare Supplement Simplified Online Application

Enrollment Trigger

Enrollment Trigger (see full list) * 🛈

Other Trigger Info *

Part A Effective date (MM-DD-YY) *

Part B Effective date (MM-DD-YY) *

Requested Eff Date (1st of any month following enrollment) *

Will your Medicare Part A and Part B be active on your supplement plan start date? *

1. The Basics

Address - Residence *

City *

State *

Zip Code *

Address - Mailing if different

Phone Number *

Email for Confirmation * 🛈

2. Household

Primary Member

First Name *

Last Name *

Date of Birth * +

Marital Status *

Medicare Number (MIB) * 🛈

SS# * 🛈

Gender *

4. Eligibility

Did you turn 65 years of age in the last 6 months? * 🛈

Did you enroll in Medicare Part B in the last 6 months? *

Questions about Medi-cal

Are you covered for medical assistance through California's Medi-Cal program? NOTE: If you have not met your share of cost under the Medi-cal program, please answer NO to this question *

Will Medi-Cal pay your premiums for this Medicare supplement policy? *

Do you receive any benefits from Medi-Cal OTHER THAN payments toward your Medicare Part B Premium? *

Questions about Medicare Advantage Plans (sometime called Medicare Part C)

Have you had coverage from any Medicare plan other than original Medicare within the past 123 days (for example, a Medicare Advantage plan, a Medicare HMO, or PPO)? *

Start date (MM-DD-YY) *

End date (MM-DD-YY) *

If you are still covered under the Medicare plan other than original Medicare, do you intend to replace your current coverage with this new Medicare supplement policy? (When you receive confirmation that this Medicare Supplement plan has been issued, you will need to cancel your Medicare Advantage Plan. Please contact your Medicare Advantage insurer for instructions on how to cancel, using the customer service number on the back of your ID card.) If YES, please enclose a copy of the Replacement Notice. *

Was this your first time in this type of Medicare plan? *

Did you drop a Medicare supplement policy to enroll in the Medicare plan? *

Questions about Medicare Supplement Plans

Do have another Medicare supplement policy in force? *

Insurance Company and Policy *

Do you intend to replace your current Medicare supplement with this policy? If YES, please enclose a copy of the Replacement Notice (we'll get this from you directly) *

What is the plan code of your current Medicare Supplement Plan? *

Questions about any other type of health insurance coverage

Have you had coverage under any other health insurance within the last 63 days (for example, an employer, union,or individual plan)? *

Insurance Company *

What kind of plan? *

If other *

What are dates of coverage under the other policy? Leave the end date blank if you are still covered under the policy. *

Are you replacing this health insurance? *

5. Plan Selection

You can run your quote HERE.

Supplement Plan

Carrier *

Plan * 🛈

What is AARP number? If not a member, we'll send the form. *

Dental (if enrolling)

Do you want dental/vision quotes and information sent to you? 🛈

Payment

How do you want to pay (not required at time of enrollment) * 🛈

Bank Name *

Account Type * 🛈

Bank Routing Number *

Bank Routing Number Confirmation *

Bank Account Number *

Bank Account Number Confirmation *

5. Terms and Conditions

If you are not in a guaranteed issue situation (new to Medicare, etc), we will send you additional steps and authorizations in regards to medical underwriting. Below are the core applications terms and you'll get an emailed confirmation with full details as well.

READ CAREFULLY, AND SIGN AND DATE WHERE INDICATED.
• I affirm that the answers on this Application Form are complete and true to the best of my knowledge and belief and are the basis for issuing coverage. I understand that the Application Form becomes a part of the insurance contract and that if the answers are untrue, the carrier may have the right to rescind my coverage or adjust my premium.
• For your protection State law requires the following to appear on this Form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
• I understand coverage, if provided, will not take effect until issued by the carrier, the actual premium is not determined until coverage is issued and that this Application Form and payment of the initial premium does not guarantee coverage will be provided.
• I acknowledge receipt of the Guide to Health Insurance for People with Medicare and the Outline of Coverage.
• A rate guide is available that compares the policies sold by different insurers. You can obtain a copy of this rate guide by calling the Department of Insurance’s consumer toll-free telephone number (1-800-927-HELP), by calling the Health Insurance Counseling and Advocacy Program (HICAP) toll-free telephone number (1-800-434-0222), or by accessing the Department of Insurance’s Internet Web site (www.insurance.ca.gov).

If the Application Form is being completed through an Agent or Broker:

• I understand an agent or broker discussing Plan options with me is appointed by the carrier, and may be compensated based on my enrollment in a Plan.
• I understand that an agent or broker cannot change or waive any terms or requirements related to this Application Form and its contents, underwriting, premium or coverage and cannot grant approval.

Please note: The pre-existing condition exclusion does not apply to you if you are in your Open Enrollment or entitled to guaranteed issue.

E-Signature * 🛈

clear

Today's Date * 🛈 +

What to Expect:

Email Confirmation - Usually received within 24 hours (business hours 9am-5pm Monday-Friday) of completed application with plan, rate, and effective date.

Confirmation by Mail from Carrier - Usually within 5-7 business days from email confirmation

IMPORTANT: 1st invoice activates the account and must be paid within 15 days of enrollment (email confirmation).

We advise creating an online account with the carrier. Please reach out with any questions!

Save & Return

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