Form Tx-Ms-App-Gi-2011-R1 - Application For Medicare Supplement Insurance Plan Page 2
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4Applicant Name __________________________________________
Medicare Claim Number
Please copy the Medicare Claim Number from your red, white and blue Medicare Card. This number must be provided to
us to complete your application process.
0 1
Part A Effective Date:
___ ___ /___ ___ /___ ___ ___ ___
■■■
■■
■■■■■■■■
–
–
0 1
Part B Effective Date:
Your Medicare Claim No.
___ ___ /___ ___ /___ ___ ___ ___
(if applicable)
Consumer Protection Information
If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were
eligible for guaranteed issue of a Medicare Supplement insurance policy, or that you had certain rights to buy such a policy,
you may be guaranteed acceptance in one or more of our Medicare Supplement plans. Please include a copy of the notice
from your prior insurer with your application.
Please answer all questions. Please mark Yes or No below with an “X” to the best of your knowledge.
1. Did you turn age 65 in the last 6 months?
Yes
■
No
■
■
■
2. Did you enroll in Medicare Part B in the last 6 months?
Yes
No
__ __ /__ __ /__ __ __ __
If yes, what is the effective date?
3. Are you covered for medical assistance through the state Medicaid program?
NOTE TO APPLICANT: If you are participating in a “Spend-Down Program”
Yes
■
No
■
and have not met your “Share of Cost,” please answer NO to this question.
Yes
■
No
■
a. If yes, will Medicaid pay your premiums for this Medicare Supplement policy?
b. If yes, do you receive any benefits from Medicaid OTHER THAN payments toward
■
■
Yes
No
your Medicare Part B premium?
4. If you had coverage from any Medicare plan other than original Medicare
Start:
__ __ /__ __ /__ __ __ __
within the past 63 days (for example, a Medicare Advantage plan, or a
Medicare HMO or PPO), fill in your start and end dates. (If you are still
End:
__ __ /__ __ /__ __ __ __
covered under this plan, leave “END” blank.)
Yes
■
No
■
a. If you are still covered under the Medicare plan, do you intend to replace your
current coverage with this new Medicare Supplement policy?
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
■
■
■
5. Do you have another Medicare Supplement or Medicare Advantage policy in force?
Yes
No
__________________________________
a. If so, with what company, and what plan do you have?
Yes
■
No
■
b. If so, do you intend to replace your current Medicare Supplement or Medicare
Advantage policy with this policy?
6. Have you had coverage under any other health insurance within the past 63 days?
Yes
■
No
■
a. If so, with what company, and what kind of policy?
__________________________________
(For example, an employer, union, or individual plan)
Start:
b. What are your dates of coverage under the other policy?
__ __ /__ __ /__ __ __ __
(If you are still covered under the other policy, leave “END” blank.)
End:
__ __ /__ __ /__ __ __ __
— 2 —
TX-MS-APP-GI-2011-R1
54876.0811 TX
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