TEST - 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 marketingsupportcoordinators@bcbsnd.com 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

Producer First Name

Producer Last Name

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

BCBSND Agent Number

BCBSND Agency Number

Applicant Information

First Name

Middle Initial

Last Name

Suffix

Social Security Number

Date of Birth

Please enter a valid date: mm-dd-yyyy

Requested Effective Date

Please enter a valid date: mm-dd-yyyy

Residential Street Address

Residential Street Address (Cannot be a P.O. Box)

City

ZIP Code

Mailing Address

Same as Physical Address? Yes

Mailing Address

City

ZIP Code

Remove

Phone Number

Add Another +

Email Address

Yes

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.

Hospital (Part A) Coverage Start Date

Please enter a valid date: mm-dd-yyyy

Medical (Part B) Coverage Start Date

Please enter a valid date: mm-dd-yyyy

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First Name : Edit

Middle Initial : Edit

Last Name : Edit

Gender : Edit

Social Security Number : Edit

Date of Birth : Edit

Residential Street Address (Cannot be a P.O. Box) : Edit

City : Edit

State : Edit

ZIP Code : Edit

County : Edit

Mailing Address : Edit

City : Edit

State : Edit

ZIP Code : Edit

County : Edit

State in which you reside : Edit

Phone Number

Phone Number : Edit

Type of Phone : Edit

Email Address : Edit

Have you used tobacco in any form in the past 12 months? : Edit

Medicare Number : Edit

Hospital (Part A) Coverage Start Date : Edit

Medical (Part B) Coverage Start Date : Edit

Were you eligible for Medicare before January 1, 2020? : Edit

Did you turn age 65 in the last 6 months? : Edit

Did you enroll in Medicare Part B in the last 6 months? : Edit

Are you covered for Medical Assistance through the state Medicaid program? : Edit

Have you had coverage from any Medicare plan other than the original Medicare within the last 63 days? : Edit

Do you have another Medicare supplement policy in force? : Edit

Have you had coverage under any other health insurance within the past 63 days? : Edit

Include any relevant supporting documentation for the application (Optional) : Edit

I acknowledge receipt of the Outline of Coverage and Guide to Health Insurance For People With Medicare.

I understand that any company(s) with which I am applying for coverage reserves the right to accept or decline this application in whole or in part. I further understand that no contractual right is created by this application or advance premium payment and the same shall not be considered accepted unless or until the Benefit Plan is issued to me. I have read this application in its entirety (including the back page) and understand and acknowledge that the accuracy and sufficiency of the information I provide (or fail to provide) in each and every numbered section of this application serves as the basis in determining my eligibility (and the eligibility of my dependents) for coverage and receiving a Benefit Plan(s), and by signing this application I certify the information is accurate and complete. I understand and agree that inaccurate, incomplete or omitted information represented in this application may constitute a fraudulent act or intentional misrepresentation of material facts voiding or retroactively canceling any Benefit Plan(s) issued, as well as any claims for medical benefits and services paid, based on the information I submit through this application. I further understand a person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

Applicant's First Name

Applicant’s Last Name

Applicant's Signature

By checking this box, I understand I am creating an electronic signature that carries the same legal obligations as a written signature and am agreeing to all of the terms and conditions set forth within this application, including the Notification and Authorization.

Producer First Name : Edit

Producer Last Name : Edit

BCBSND Agent Number : Edit

BCBSND Agency Number : Edit

Agent Initials

I have distributed a copy to the applicant of the Outline of Coverage and Guide to Health Insurance For People With Medicare.

Have you sold to this applicant any other health insurance policies which are still in force? Yes

Have you sold to this applicant in the past five years any other health insurance policies which are no longer in force? Yes

Agent's Signature

I am submitting this application on behalf of the individual signee. I have received verbal or written consent from the individual to submit the application. The application accurately reflects the information provided. I have printed a copy of the application and provided it to the individual signee.

Print this Page

Print this page for your records before submitting the application. To see all information, ensure all content is expanded on page when printing.

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TEST - Medicare Supplement Application

Producer/Broker Information

Applicant Information

Residential Street Address

Mailing Address

Coverage Plans

Additional Information

Review and Sign