TEST Enrollment Form

Agent*
Sale(s) Description*
List carrier, name of plan, proposed effective date, premium and any policy fee. If multiple sales (ie Medsup and PDP) include both entries.
First Name*
First name as it appears on Medicare card
Middle Initial
Middle initial (if any) as it appears on Medicare card
Last Name*
Last name as it appears on Medicare card
Birthdate*
Date of Birth
Month
Day
Year
Gender*
- M
- F
Phone*
Phone number
Email
Email address
Address*
Residence Street Address (no PO Box)
Unit
Unit or Apt #
City*
City of Residence
County*
County of Residence
State*
State of Residence
Zip Code*
Residence Zip Code
Have a Preferred Mailing Address Different than Residence?*
- Yes
- No
Mailing Address
Preferred Mailing Address
Mailing Unit
Unit or Apt #
Mailing City
Mailing Address City
Mailing State
State of Mailing Address
Mailing Zip Code
Mailing Zip Code
Applying in which state?*
- Arizona
- Arkansas
- California
- Colorado
- Florida
- Georgia
- Idaho
- Illinois
- Michigan
- Missouri
- Montana
- Nevada
- New Jersey
- New York
- North Carolina
- Oregon
- Pennsylvania
- South Carolina
- Tennessee
- Texas
- Virginia
- Wisconsin
- Other (confirm agency appointment in state)
Enrolling in (select all that apply)*
- Medsup
- PDP
- Medicare Advantage
- Cancer
- Dental/Vision
- Other (include in Sale Description section)
Has a telephonic Scope of Appointment Been electronically collected?*
- Yes
- No
By electronically signing this scope of appointment, you agree to discuss Medicare Part D plans and/or Medicare Advantage plans with a licensed agent. Please note that the person who will discuss these Medicare plans is contracted by insurance companies and Medicare plans. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. This agreement does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.
Why was SOA not required?*
- Sale resulted from Formal/Informal Sales event reported to CMS
- Sale resulted from Educational event
- Other (explain in Sales Description)
Did you run an Rx report?*
- Yes
- No
Why was an Rx report not required?*
- Client confirmed no prescriptions
- Other (explain in Sales Description)
Required MAPD Disclosure*
Medicare Life Group strongly recommends a cancer plan for Medicare Advantage clients: Medicare Advantage plans typically have a 20% chemotherapy co-pay. This causes most cancer patients to hit their maximum out-of-pocket quickly and a late year diagnosis can cause them to hit it twice in just a few months.
- Disclosure read to client
- Disclosure skipped
Client Cancer insurance decision*
- Declining cancer insurance
- Enrolling in cancer insurance
Medsup Enrollment type*
- Initial Enrollment Period
- Guaranteed Issue
- Underwritten
Reason for Medsup Guaranteed Issue*
For example, lost coverage, moved, MAPD trial period, etc.
Remind client that carrier will call with UW questions
Medsup Carrier*
Medsup Plan Type*
Medsup Premium Amount (not including any HH discount)*
Do you have a spouse?*
Household discounts may apply
- Yes
- No
Name of spouse*
Spouse Notes: particularly for use in HH discount determination
spouse SSN, spouse Medsup carrier, spouse AARP #, etc.
Household Discount?*
- Yes
- No
Is there a Policy Fee?*
- Yes
- No
Policy fee amount*
Total Initial Premium with Policy Fee and HH Discount
Total Initial Premium with Policy Fee
Total Premium with Household Discount
Tobacco in last 12 months?*
- Yes
- No
Tobacco in last 12 months?*
- Yes
- No
Tobacco in last 12 months?*
- Yes
- No
Tobacco in last 12 months?*
- Yes
- No
Tobacco Rates Will Apply. What is monthly Medsup premium for tobacco?*
Tobacco Rates Will Apply. What is monthly Medsup premium for tobacco?*
Tobacco Rates Will Apply. What is monthly Medsup premium for tobacco?*
Tobacco Rates Will Apply. What is monthly Medsup premium for tobacco?*
PDP Enrollment type*
- IEP - Initial Enrollment Period (new to Medicare)
- IEP2 - Aging in (Turning 65 and eligible for Medicare prior to age 65)
- AEP - Annual Enrollment Period (Oct 15 - Dec 7)
- SEP - Special Enrollment Period
Reason For SEP*
- Loss EGHP
- Change in residence
- OEP - disenrolling from MAPD
- Institutionalized
- Invol Loss Creditable Cvg
- SEP 65 (joined MAPD T65 and leaving)
- Medigap trial period (dropped Medigap for MAPD)
Reminder: LEP letter due to EHGP
PDP Carrier*
Aetna PDP Plan Type*
Humana PDP Plan Type*
Blue Shield PDP Plan Type*
Montana BCBS PDP Plan Type*
Silverscript PDP Plan Type*
United Healthcare PDP Plan Type*
Wellcare PDP Plan Type*
PDP Premium*
PDP Quoted Premium Amount
MedAdv Enrollment type*
What is the client's Election Period?
- IEP - Initial Enrollment Period (New to Medicare)
- IEP 2 - Aging In (turning 65 and eligible for Medicare prior to age 65)
- ICEP - Delayed Part B enrollment (eff date BEFORE Part B)
- AEP - Annual Enrollment Period (Oct 15- Dec 7)
- SEP - Special Enrollment Period
- OEP - MAPD Open Enrollment Period Switch (Jan 1-Mar 31)
- OEPI - Institutionalized
Reason for MedAdv SEP*
- Change in Residence
- Loss of EGHP
- Invol Loss Creditable Cvg
- Contract termination
- Weather related emergency
Medicare Advantage Carrier*
Aetna MedAdv Plan Type*
Alignment MedAdv Plan Type*
Blue Shield MedAdv Plan Type*
Humana MedAdv Plan Type*
Montana BCBS MedAdv Plan Type*
United Healthcare MedAdv Plan Type*
MedAdv Plan ID Number*

This number can be found via the quoting tool.
MedAdv Quoted Premium Amount*
Cancer Insurance Carrier*
Cancer Insurance Lump Sum Amount*
- $5K
- $10K
- $15K
Cancer Insurance Quoted Premium Amount*
AARP Number*
Are you a US citizen?*
- Yes
- No
Will you be a US citizen at the time of your effective date?*
- Yes
- No
If answer to this question is "No" then client is not eligible for a policy.
State or country of birth*
Medicare Number*
Medicare Claim Number
Part A Effective Date*
Part A Effective Date
MM slash DD slash YYYY
Part B Effective Date*
Part B Effective Date
MM slash DD slash YYYY
Social Security Number*
Social Security Number
Height and Weight
List all medical conditions in the past 2 years*
Current prescriptions*
List all current prescriptions, dosages, reasons, and when first prescribed
Currently residing in nursing home?*
- Yes
- No
Currently on Medicaid?*
- Yes
- No
Currently on Medi-Cal?*
- Yes
- No
Medicaid Number*
Medi-Cal Number*
Have prescription drug coverage that will continue after enrolling?*
Usually military-related, for example, Tricare or VA coverage.
- Yes
- No
Name of other Rx Coverage*
Spouse Date of Birth*
Month
Day
Year
Currently working or retired?*
- Working
- Retired
Currently have Medicare Advantage plan in force?*
- Yes
- No
Name of Current Med Adv Carrier*
Currently have Medsup plan in force?*
- Yes
- No
Name of current Medsup carrier*
Current Medsup plan type*
Plan F, Plan G, etc.
If currently have MAPD/Medsup plan, when does coverage end?
MM slash DD slash YYYY
Is current Medsup plan being replaced?
- Yes
- No
Is current MAPD plan being replaced?
- Yes
- No
Reason for replacing Medsup coverage
- Additional Benefits
- No change in benefits, but lower premiums
- Fewer benefits and lower premiums
Reason for replacing MAPD coverage
- Plan has outpatient Rx drug coverage and applicant is enrolled in Part D
- Disenrollment from MAPD plan
Please explain reason for MAPD disenrollment
Have other health insurance coverage in past 63 days?*
- Yes
- No
Current health insurance company*
Insurance carrier
Type of current health insurance plan*
Employer, HMO, major med, etc.
When did current coverage start?
MM slash DD slash YYYY
When does current coverage end?
MM slash DD slash YYYY
Primary care physician*
Primary care physician*
PCP ID #
Need to look up from carrier website
Currently have dental/vision insurance?*
- Yes
- No
Enrolling in Ameritas?*
- Yes
- No
Ameritas Plan(s) Selected (mark all that apply)*
https://www.securitylife.com/personal-plans?agnt=18324
Ameritas Enrollment Completed by Agent?*
- Yes, enrollment complete
- No, Brad will complete enrollment
Blue Shield Dental selection
Plan Details: https://blueshieldcamedicare.com/medicare-plans-california/medicare-supplement-plans/dental-plans/
- Specialty Duo dental + vision package
- Dental PPO 1000
- Dental PPO 1500
- no dental plan
Medsup Requested Effective Date*
MM slash DD slash YYYY
Requested PDP Coverage Effective Date*
PDP Effective Date
MM slash DD slash YYYY
MedAdv Requested Effective Date*
MM slash DD slash YYYY
Review Election Period Chart and Confirm Effective Date Works*
- Confirmed
- Will Confirm Later
Medsup Payment Type*
Payment Type Comment
Medsup Payment Type*
Payment Type Comment
PDP Payment Type*
PDP Payment Type*
Let client know we'll need a voided check with the application
Credit Card Company*
Credit Card Number*
Credit Card Expiration*
MedAdv Payment Type*
Wellcare will mail EFT form to client
Name of Bank*
Day of Month for Bank Draft*
Day of Month for Bank Draft*
Day of Month for Bank Draft*
Day of Month for Bank Draft*
Day of Month for Bank Draft*
Day of Month for Bank Draft*
- 1st
- 15th
Checking/Account Number*
Routing Number*
Have we sold them another health insurance plan in the last five years?*
- Yes
- None
Wellcare Plan ID
Wellcare Plan ID
- 163 (CA)
- 160 (CO)
- 146 (FL)
- 145 (GA)
- 162 (ID)
- 152 (MO)
- 158 (MT)
- 143 (NC)
- 139 (NJ)
- 141 (PA)
- 144 (SC)
- 155 (TX)
- 142 (VA)
How Would Client Like to Provide Medsup Application Signatures?*
- Email PDF
- Mail
Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.
How Would Client Like to Provide Medsup Application Signatures?*
- Instant App - just need client oral consent
- Email PDF
- Mail
Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.
How Would Client Like to Provide Medsup Application Signatures?*
- Direct Enroll
- Email PDF
- Mail
Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.
Client Favorite Color (for Direct Enroll security question)*
How Would Client Like to Provide Medsup Application Signatures?*
- LEAN - Remote Signature via UHC Email
- Email PDF
- Mail
LEAN: Client will receive email from UHC with DocuSign remote signature option. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.
How Would Client Like to Provide PDP Application Signatures?*
- LEAN - Remote Signature via UHC Email
- Email PDF
- Mail
LEAN: Client will receive email from UHC with DocuSign remote signature option. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.
How Would Client Like to Provide PDP Application Signatures?*
- Email PDF
- Mail
- Humana Electronic App
- MID
Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.
How Would Client Like to Provide PDP Application Signatures?*
- Email PDF
- Mail
- SVS Electronic App
- MID
Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.
How Would Client Like to Provide PDP Application Signatures?*
- Email PDF
- Mail
- MID
Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.
How Would Client Like to Provide MADP Application Signatures?*
- Email PDF
- Mail
- MID
Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.
How Would Client Like to Provide MADP Application Signatures?*
- Email PDF
- Mail
- Humana Electronic App
- MID
Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.
How Would Client Like to Provide MAPD Application Signatures?*
- LEAN - Remote Signature via UHC Email (Access Code is Zip Code)
- Email PDF
- Mail
LEAN: Client will receive email from UHC with DocuSign remote signature option. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.
Choose a 4 Digit PIN and favorite color for Instant App*
Health Assessment for UHC MAPD*
Client have any health conditions?
- Yes
- No
List health conditions for Health Assessment
Client Acknowledgement: Address/Billing Changes*
- I understand
- I do not understand
Unfortunately, the insurance carriers do not allow me to make any changes to your address or billing information after submitting this application. In the event you move or need to change your billing preferences, you'll be able to contact your insurance carrier directly by calling the phone number on the back of the insurance card they will provide you. Sorry for this inconvenience. That said, in the unlikely event you ever have any issues with the carrier processing your claims or other Medicare-related problems, please contact my office and we will help get everything resolved.
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