Medigap Enrollment

Are you enrolling as a new member or existing member?

Plan Selection

Please select which plan you want to enroll in:

Plan	Monthly Premium	Enroll
Plan A	$265.26
Plan B	$350.13
Plan C*	$437.68
Plan F*	$437.68
Plan High Deductible F*	$98.15
Plan G	$226.09
Plan N	$193.90

* Plans C, F and High Deductible F are only available to beneficiaries who were first eligible for Medicare prior to January 1, 2020

Proposed effective date

Applicant Information

Title

First name

Middle initial

Last name

Birth date

Sex Male Female

Social Security Number

Permanent Residence Address

Street address

(P.O. Box is not allowed)

City

State

Zip code

Home phone number

County

Email address

Alternative phone number

My mailing address is My permanent residence Different from above

Sign & Submit

Who is filling out this application?

Self (I am enrolling online without any additional assistance from any authorized representative, sales representative, or sales broker from the plan)

Sales Representative/Broker

Authorized Representative (Examples: Power of Attorney/ Legal representative)

Please enter the following information:

In addition to this policy I have sold this applicant the following policies that are still in force (attach additional sheet if necessary):

Policy #

Type

Effective Date

I have also sold this applicant the following policies in the past five years that are no longer in force (attach additional sheet if necessary):

Policy #

Type

Effective Date

First name

Middle initial

Last name

Agent ID

Signature

I understand that my signing and submitting this Agreement in this fashion is the legal equivalent of having placed my handwritten signature on the submitted application. I further understand that by electronically signing and submitting this application, I agree to adhere to the terms set forth in the application. *

I understand that any person who knowingly and with intent to defraud an insurance company files an application for insurance or statement of claim containing any materially false information or conceals information concerning any fact material thereto for the purpose of misleading commits a fraudulent insurance act which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation. *

Please enter the following information:

First name

Middle initial

Last name

Street address

City

State

Zip code

County

Phone number

Relationship to enrollee

Signature

CG1X3F0576

Medigap Enrollment

Are you enrolling as a new member or existing member?

Applicant Information

Permanent Residence Address

Mailing Address

Please answer completely and to the best of your knowledge and belief.

1.

2.

3.

4.

5.

Please enter the following information:

Please enter the following information:

Confirmation Number:

Congratulations, your application has been successfully submitted!

We're sorry, there was an error submitting your enrollment.