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Requested Policy Effective Date
Medicare Part A Effective Date
Medicare Part B Effective Date
Birth Date
Zip Code
County
Gender
(Select One)
Female
Male
Has the proposed insured used tobacco in the past year?
(Select One)
No
Yes
Is the proposed insured in Open Enrollment or Guaranteed Issue?
(Select One)
No
Yes - Open Enrollment
Yes - Guarantee Issue
Include household discount?
Yes
No
MACRA ALERT
: Applicants with Medicare Part A effective date on or after 01/01/2020 may not purchase Medicare Supplement plans that cover the Medicare Part B deductible, including select plans/riders in MA, MN and WI as well as C, F, High Deductible F, and Innovative F plans in all other states.
