Form Gr-68004-4 - Aetna Individual Medicare Supplement Plan Application Page 2
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8Aetna Individual Medicare Supplement Plan Application
Aetna Life Insurance Company, 151 Farmington Ave, MS 3128, Hartford, CT 06156
[PLEASE MAIL APPLICATIONS TO:] [PO Box 13547, Pensacola, FL 32591-3547]
1
APPLICANT INFORMATION (Proposed Policyholder) –
2
MEDICARE INFORMATION –
Please Print
Please fill out this information exactly as it
appears on your Medicare card.
Last Name
First Name
MI
Social Security Number
Birth Date
Male
MEDICARE
HEALTH INSURANCE
(MM/DD/YYYY)
Female
CENTERS FOR MEDICARE & MEDICAID SERVICES
Street Address (Number, Street, Apt.)
NAME OF BENEFICIARY
City
State
Zip Code
County
MEDICARE CLAIM NUMBER
Billing Name (if different from above)
–
–
–
IS ENTITLED
EFFECTIVE DATE
Billing Address (if different from above)
HOSPITAL (PART A)
Telephone Number
Primary Language Spoken
MEDICAL (PART B)
(
)
(optional)
E-mail Address (optional)
3
“NOTICE OF POLICY LAPSE” ADDRESSEE INFORMATION – In addition to the policyholder, a copy of any notification
of possible policy lapse will be sent to the person listed below. (Please note that this person should not reside at the
same address as the policyholder.) Name:
Address:
4
MEDICAL AND GENERAL (A telephone interview with the applicant may be conducted to verify application.)
- Please answer all questions to the best of your knowledge and belief.
Please Mark Yes or No with an “X”
To the best of your knowledge,
(1) Did you turn age 65 in the last 6-months? ................................................................................................
Yes
No
(a) Did you enroll in Medicare Part B in the last 6-months? .....................................................................
Yes
No
(b) IF YES, what is the effective date?
(2) Are you covered for medical assistance through the state Medicaid program? ........................................
Yes
No
(NOTE TO APPLICANT: Please answer NO to this question if you are participating in a “Spend-Down
Program” and have not met your “Share of Cost.”)
IF YES,
(a) Will Medicaid pay your premiums for this Medicare supplement policy? ............................................
Yes
No
(b) Do you receive any benefits from Medicaid OTHER THAN payments towards your Medicare Part B
premium? ...........................................................................................................................................
Yes
No
continued
PLEASE MAKE A COPY FOR YOUR RECORDS
Page 2 of 8
GR-680044 (4-11) NY
[C]
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