Medicare Supplementary Enrollment Application

1. Information about you

*Indicates required information

First Name: *

Last Name: *

Middle Initial:

Social Security Number: *

Address: *

Address Line 2:

City: *

State: *

Zip: *

County: *

Phone number that we may use to contact you: *

HomeCell

Alternate Phone:

Email Address:

Gender: *'

Female
Male

Rate:

Birthdate: * (enter in mm/dd/yyyy format)

Number of months you reside in Michigan each year: *

Medicare contract number (as shown on your Medicare red, white and blue card): *

Medicare Part A effective date: * (enter in mm/dd/yyyy format)

Medicare Part B effective date: * (enter in mm/dd/yyyy format)

Please indicate your requested effective date (the first day of a month, month/day/year): *

Your coverage will become effective on the first day of the month following receipt of your completed application or the date specified above (if agreed to by McLaren). You will receive an I.D. card and a certificate of coverage with a letter confirming your effective date and premium.