Form Gr-68004-4 - Aetna Individual Medicare Supplement Plan Application Page 3
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8Applicant’s Name
Social Security Number
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MEDICAL AND GENERAL (Continued)
(3) If you had coverage from any Medicare plan other than the original Medicare plan within the last 63 days
(for example, a Medicare Advantage plan or a Medicare HMO or PPO), fill in your start and end dates
below. If you are still covered under this plan, leave “END” blank.
START
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/
END
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(a) If you are still covered under the Medicare plan, do you intend to replace your current coverage
with this new Medicare supplement policy?........................................................................................
Yes
No
(b) Was this your first time in this type of Medicare plan?........................................................................
Yes
No
(c) Did you drop a Medicare supplement policy to enroll in the Medicare plan? ......................................
Yes
No
(4) Do you have another Medicare supplement policy in force?.....................................................................
Yes
No
IF YES,
(a) With what company and what plan do you have?
(b) Do you intend to replace your current Medicare supplement policy with this policy? .........................
Yes
No
(5) Have you had coverage under any other health insurance plan within the past 63 days? (for example,
an employer, union or individual plan).......................................................................................................
Yes
No
IF YES,
(a) With what company and what kind of policy?
(b) What are your dates of coverage under the policy? (if you are still covered under the other policy,
leave “END” blank).
START
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END
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PLAN SELECTION AND PREMIUM PERIOD OPTIONS
a. Select the Medicare Supplement Plan you are applying for: (choose one)
[
Plan A
Plan B
Plan F]
b. Select your Premium Period: (choose one) - This is the frequency at which you want to pay your premiums.
[
Monthly]
[
Quarterly]
[
Semi-Annual]
[
Annual]
c. Monthly Premium Rate
$
(The monthly premium rate can be found in the Outline of Coverage.)
PLEASE MAKE A COPY FOR YOUR RECORDS
Page 3 of 8
GR-68004-4 (4-11) NY
[C]
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