Complete the form below selecting your Plan and Carrier.  A confirmation of Plan enrollment will be sent to the email address you provide.  Plan Identification Cards and other important information will be mailed to you within 7 to 10 days.

If you want to talk about carrier or plan selection,  call or email us. 


Select the Medigap policy you want to buy:
*Only applicants eligible for Medicare prior to 1/1/2020 may purchase Plan C, Plan F or High Deductible Plan F.
Please select the carrier providing the Medicare Supplement Plan you want to buy.
Please provide the information requested below to process your application: ( * = required)
(only if different from above Street Address)
(only if different from above Street Address)
1. Are you covered for medical assistance through the State Medicaid program?
(NOTE TO APPLICANT: If you are participating in a "Spend-Down Program" and have not met your "Share of Cost," please answer NO to this question.
a. If yes, will Medicaid pay your premiums for this Medicare Supplement policy?
b. Do you receive any benefits from Medicaid OTHER THAN payments toward your Medicare Part B premium?
2. If you had coverage from any Medicare Advantage plan other than Original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you are still covered by this plan, leave "END" blank.
a. If you are still covered under the Medicare Advantage 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 Advantage plan?
c. Did you drop a Medicare Supplement policy to enroll in the Medicare Advantage plan?
3. Do you have another Medicare Supplement or Medicare Select policy or certificate in force?
b. If so, do you intend to replace your current Medicare Supplement or Medicare Select policy or certificate with this policy or certificate?
4. Have you had coverage under any other health insurance policy or certificate within the past 63 days? (For example, an employer, union, or individual plan.)
b. What are your dates of coverage under this policy? (If you are still covered under this policy, leave "END" blank.)
5. Do you intend to replace your current healthcare coverage with this Medicare Supplement policy?
I hereby authorize Carrier to initiate debit/credit entries to my checking/savings account, as indicated below, in amounts appropriate to my coverage; and authorize the bank named below to debit/credit the same to such account. I authorize Carrier to change the amount of the debit/credit, provided that I am given advance written n otice. This authorization is to remain effective until I give Carrier and the bank reasonable notice of termination.
(Please type your name)

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