Group Coverage Application Form
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4GROUP COVERAGE
APPLICATION FORM
A
TO APPLY FOR MEDIGAPSECURITY. . .
Check plan option which is available through your group. If you are unsure of your options, please contact your group:
Plan A
Plan B
Plan C
Plan F
High Deductible Plan F
Plan N
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Desired effective date: ____________________________________
LAST Name:
FIRST Name:
Middle Initial:
Mr.
Mrs.
Ms.
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Sex:
Phone Number:
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Age:
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Birth Date:
Social Security #:
Permanent Residence Street Address:
City:
State:
ZIP Code:
Mailing Address (only if different from your Permanent Residence Address):
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Street Address:
City:
State:
ZIP Code:
Emergency Contact: _________________________________
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Phone Number:
Relationship to You:
Email Address: ____________________________________
B
PLEASE PROVIDE YOUR MEDICARE INSURANCE INFORMATION
Please take out your Medicare Card to complete
this section.
• Please fill in these blanks so they match your red, white, and
SAMPLE ONLY
blue Medicare card.
Name: ________________________________________
Medicare Claim Number
Sex _________
– OR –
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• Attach a copy of your Medicare card or your letter from the
Social Security Administration or Railroad Retirement Board.
Is Entitled To
Effective Date
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You must have Medicare Part A and Part B to join
HOSPITAL (Part A)
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MedigapSecurity.
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MEDICAL (Part B)
08531
15627 (2009-0205b) 5/11
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