HDA Insurance Brokerage
Medicare Advantage Plan Individual Enrollment

Applicant Information

Name:
Date of Birth:
SSN:
Sex:(M/F)
Current Address:
City:
State:
Zip:
Phone:
Mobile Phone:
E-Mail:

Medicare Card Information

Name: (Exactly as printed on card)
Medicare Claim Number:
Hospital: (Part A)
Effective Date:
Hospital: (Part B)
Effective Date:
Comments:

Underwriting Questions

1. Do you have End Stage Renal Disease (ESRD)?
2. Will you have other prescription drug coverage in addition to the plan applied for?
3. Are you a resident in a long-term care facility?
4. Are you enrolled in your State Medicaid program?
5. Do you or your spouse work?

Underwriting Questions

Comments:

HDA Insurance Brokerage will enter the above information on the appropriate application to be signed by applicant.

PLEASE NOTE: NO COVERAGE IS EFFECTIVE UNTIL CONFIRMED BY CARRIER!

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