Medicare Supplement Application

Attention: Only agents that are currently appointed with BCBSND are authorized to submit applications. If you are not appointed or are unsure of your appointment status with BCBSND, contact prior to submitting any applications.

Action required: At the time of application, you are required to distribute a copy of "Choosing a Medigap Policy" and the "Medicare Supplement Outline of Coverage" to the applicant.

Information you will need

  • Name as it appears on applicant's Social Security Card
  • Medicare Card with Medicare Number, if available, along with Hospital and Medical Coverage start dates.
    • Note: New Medicare members awaiting their Medicare card and Medicare Number may provide their expected Hospital and Medical start dates for now.

Producer/Broker Information

*Required fields

Note: Include leading zeros in BCBSND Agent Number and BCBSND Agency Number.

Applicant Information

Please enter a valid date: mm-dd-yyyy
Please enter a valid date: mm-dd-yyyy

Residential Street Address

Mailing Address

Please fill out your Medicare Number, Hospital and Medical Coverage start date as it appears on your Medicare card. BCBSND will be unable to process your claims if this information is not correct. You must be enrolled in both Hospital Part A and Medical Part B to be eligible for this Medicare Supplement Plan.

Please enter a valid date: mm-dd-yyyy
Please enter a valid date: mm-dd-yyyy

Coverage Plans

Rates subject to change. Enrollment subject to approval.

Additional Information

Max size for upload is 10MB. Acceptable file formats include: .pdf and image files.

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