Enrollment Request Form - 2017 Page 13

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For licensed sales representative/agency use only.
New Member
Employer Group Name
Plan Change
Employer Group ID
Branch ID
Where did this application originate?
□ Retail/Mall Program
□ Local Event Outreach
□ Local B2B Outreach
□ Member Meeting
□ Community Meeting
□ Other
How was this application submitted?
Appointment
Other
Mail In
Licensed Sales Representative/Writing ID
Initial Receipt Date
M M
/
D D
/
Y Y Y Y
Licensed Sales Representative/Agent Name
Proposed Effective Date
/
/
M M
D D
Y Y Y Y
Licensed Sales Representative Phone Number (
)
--
Agent must complete
AEP
IEP
IEP 2
SEP (Institutional)
SEP (Dual Eligible)
SEP - GEP Part B
SEP (SEP Reason)
SEP Eligibility Date
M M
/
D D
/
Y Y Y
Licensed Sales Representative Signature (required)
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies,
a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan’s contract
renewal with Medicare. UnitedHealthcare Insurance Company pays royalty fees to AARP for the
use of its intellectual property. These fees are used for the general purposes of AARP. AARP and
its affiliates are not insurers. You do not need to be an AARP member to enroll. AARP encourages
you to consider your needs when selecting products and does not make specific product
recommendations for individuals.
This information is available for free in other languages. Please call our customer service number
at 1-888-867-5564, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.
Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al
Cliente al número 1-888-867-5564, TTY 711, de 8 a.m. a 8 p.m. hora local, los 7 días de la semana.
本資訊也有其他語 的免費版本。請撥打1-888-867-5564, 聯絡我們的客戶服務部, 聽語障專
線711, 每週 7 天, 當地時間上午 8 時至晚上 8 時
PDEX17PD3877053_000
Y0066_160609_110859 Approved

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