Form Tx-Ms-App-Gi-2011-R1 - Application For Medicare Supplement Insurance Plan
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1
2
3
4Application for Medicare
Supplement Insurance Plan
Instructions
HOME OFFICE USE ONLY
1.
To be considered for coverage, you must have Medicare Parts A and B, reside in Texas,
and be: a) age 65 or over or b) applying within 6 months of your Medicare Part B effective date.
2.
If submitting a paper application, please complete in ink. Be sure to sign and date on the
appropriate line(s) on pages 3 and 4. Send no money now! No payment is due until you have
a chance to review your policy and make sure the coverage is right for you.
3.
If you meet the eligibility requirements for under age 65 disability, you are only eligible for Plan A.
Plan Selection
Check one box to apply for a Medicare Supplement Insurance plan.
Plan A
Plan F
Plan F
Plan G
High Deductible
Standard
Standard
Medicare Select
Medicare Select
Plan N
Plan K
Plan L
Standard
Standard
Standard
Medicare Select
Medicare Select
Medicare Select
See the enclosed Outline of Coverage for rate information
Requested Policy
Effective Date
MONTH
DAY
YEAR
Applicant Information
Preferred Method of Contact:
■
Mail
■
Phone
■
Email
Name (First)
(Middle)
(Last)
Home Address (No P.O. Boxes)
City
State
Zip
TX
Correspondence/Billing Address
City
State
Zip
Age
Primary Phone
Secondary Phone
Date of Birth
___ ___ /___ ___ /___ ___ ___ ___
(
)
(
)
Mo.
Day
Year
Gender
Social Security Number
Email address
___ ___ ___ -___ ___ -___ ___ ___ ___
■
■
Male
Female
Payment Option
(Select one payment option)
1.
■
Premium deducted from bank account: (choose one):
■
Checking
■
Savings
Account holder name: ___________________________________________________________________________
Bank name: _________________________________________________________________________________
Bank routing #: ______________________________ Bank account #: ____________________________________
X
Account Owner Signature (if different than applicant)
__________________________________________________
2.
Premium to be billed by mail
■
3. I will pay my premium:
■
Monthly
■
Bi-Monthly
■
Quarterly
■
Semi-Annually
■
Annually
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
54876.0811 TX
TX-MS-APP-GI-2011-R1
Blue Cross and Blue Shield of Texas, P.O. Box 3003, Naperville, IL 60566-7003
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