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Medicare Supplement Intake Form

Complete this form and Mercy's team will contact you to find the best supplement plan for your needs.

Section 1 of 7 — Medicare Info5% complete

1 · Medicare

2 · Personal

3 · Plan

4 · Eligibility

5 · Agent

6 · Payment

7 · Enrollment

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Step 1 — Medicare Information

Medicare numbers and effective dates.

AARP Member Number

Medicare Number *

Medicare Part A Effective Date *

Medicare Part B Effective Date *

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Step 2 — Personal Information

Basic details about the applicant.

First Name *

Middle Initial

Last Name *

Street Address *

City *

County

State *

ZIP Code *

Phone Number *

Email Address *

Date of Birth *

Gender *

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Step 3 — Plan Choice

Select your desired Medicare Supplement plan.

Select Plan Option

Plan F Plan G Plan N

Requested Effective Date

Active Part A & B on start date? *

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Step 4 — Eligibility Questions

Answer these questions to confirm eligibility.

Start date within 6 months of turning 65 or Part B enrollment?

Yes No

Do you have guaranteed issue rights?

Yes No

Used tobacco in the past 12 months?

Yes No

Did you turn age 65 in the last 6 months?

Yes No

Enrolled in Part B in the last 6 months?

Yes No

Covered by state Medicaid program?

Yes No

Other Medicare plan (non-original) in past 63 days?

Yes No

Another Medicare supplement policy in force?

Yes No

Intend to replace current policy?

Yes No

Other health insurance in past 63 days?

Yes No

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Step 5 — Agent / Broker Use Only

Insurance history as issued by broker.

Other health insurance policies issued to applicant

Policies still in force

Lapsed policies in past 5 years

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Step 6 — Bank Account Information

Used for premium payments.

Account Holder Name

Bank Name

Account Type

Routing Number

Account Number

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Step 7 — Notes & Enrollment Details

Final remarks and office enrollment info.

Additional Notes

PDP Details

Premium Amount

Enrollment Date

Confirmation #

By submitting, you certify that all information provided is accurate and complete.

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