Form Gr-68004-4 - Aetna Individual Medicare Supplement Plan Application (Page 4 of 8) in pdf

Form Gr-68004-4 - Aetna Individual Medicare Supplement Plan Application Page 4

Applicant’s Name

Social Security Number

PREMIUM PAYMENT OPTIONS - Total Amount you are Submitting for the Premium Period Selected in [5b].

IMPORTANT NOTE: Your monthly premium rate will differ depending on the Plan you choose and how you choose to pay.

If you choose to pay using Electronic Funds Transfer (EFT) [or with a Credit Card], the monthly premium rate will be the

same as shown in your Outline of Coverage. If you choose to have us bill you each month (Direct Billing), your monthly

premium rate will be $[2] more than the monthly premium rate shown in your Outline of Coverage. (You will see where to

choose your payment option and how to calculate the amount below.)

MONTHLY PREMIUM RATE* - Amount from [5c] above, plus the adjustment for choosing the Direct Billing option, if

applicable.

a) Monthly Premium Rate $

(EFT [or Credit Card amount])

b) Monthly Premium Rate $

(Direct Billing amount – please add $[2] to the rate shown above in [5c])

QUARTERLY PREMIUM RATE – (monthly rate from line [5c] multiplied by 3)

SEMI-ANNUAL PREMIUM RATE - (monthly rate from line [5c] multiplied by 6) $

ANNUAL PREMIUM RATE (monthly rate from line [5c] multiplied by 12)

*If you are paying with a personal check, you must include at least the first month’s premium with your

application.

Please make checks payable to [Aetna Life Insurance Company].

REQUESTED EFFECTIVE DATE: 1

(month)

PLEASE MAKE A COPY FOR YOUR RECORDS

Page 4 of 8

GR-68004-4 (4-11) NY

[C]

Form Gr-68004-4 - Aetna Individual Medicare Supplement Plan Application Page 4