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Application Form
AARP
®
Medicare Supplement Insurance Plans
Insured by
UnitedHealthcare Insurance Company (UnitedHealthcare),
Horsham, PA 19044
Instructions
Fill in all requested information on this Application Form and sign in all places a signature is needed.
Note: Plans and rates are only good for residents of the state of New Jersey. The information you provide on this
Application Form will be used to determine your acceptance and rate.
1
Provide additional information about yourself and your Medicare Insurance.
___________________________ _________________________________________________________
1A. Phone Number 1B. Email address (optional). Include periods (.) and symbols (@).
By providing your address, phone number and/or email address, you are agreeing to receive information and be contacted
by UnitedHealthcare Insurance Company.
1C. Birthdate ________________________ 1D. Gender _____________
Month Day Year
1E. Medicare Number _____________________________ (From your Medicare card.)
1F. Medicare Start: Hospital (Part A) ____________________ Medical (Part B) ___________________
Month Year Month Year
1G. Will your Medicare Part A and Part B be active on your AARP Medicare Supplement Plan start date? _____________
AARP Membership Number (If you are already a member) ___________________________________________
_____________________________________ ____ __________________________________________
Applicant First Name MI Last Name
Permanent Home Address (P.O. Box/PMB is not allowed)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Mailing Address (if different from permanent address)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
____________________________
____________________________
____________________________
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2
Choose your Plan and start date.
3
Is your acceptance guaranteed?
Plan Choice
2A. You are eligible to apply if all of these are true:
• you are an AARP member,
• you are age 50 or older,
• you are enrolled in Medicare Parts A and B,
• you are not enrolled in more than one Medicare supplement plan at the same
time,
• if you are age 65 or older and are entitled to guaranteed acceptance, please
look at “Your Guide” to determine which Plans you are eligible for guaranteed
acceptance in without having to answer health questions.
• if you are age 50-64 and eligible for Medicare by reason of disability or
End-Stage Renal Disease (ESRD):
You are eligible for Guaranteed Acceptance in Plan C if your
Medicare Part B effective date is prior to 1/1/2020 and you apply:
- within six months of enrollment in Medicare Part B; or
- within six months beginning with the month in which a retroactive
determination of eligibility for Medicare is made.
You are eligible for Guaranteed Acceptance in Plan D if your
Medicare Part B effective date is prior to 1/1/2020 and you apply:
- within six months of enrollment in Medicare Part B and you are not covered
by any other Medicare Supplement Plan; or
- your Medicare Part B effective date is on or after 1/1/2020 and you apply
within 12 months of enrollment in Medicare Part B.
_________________________
Plan Start Date
2B. Your Plan will start on the first day of the month following receipt and
approval of this Application Form and receipt of your first month’s payment. If
you would like your Plan to start on a later date (the first day of a future month),
please indicate the date:
____________________
Month Day Year
3A. Will your AARP Medicare Supplement Plan start date be within 6 months after: you
turn age 65 or enroll in Medicare Part B or the beginning of the month that a retroactive
determination of eligibility for Medicare is made (12 months for Applicants age 50-64
eligible for Medicare by reason of disability or End-Stage Renal Disease who are enrolling
in Plan D and who first enrolled in Medicare Part B on or after 1/1/2020)?
____________________
• If YES, your acceptance is guaranteed. Go directly to Section 9. You do not have to
answer the questions in Sections 4, 5, 6, 7 and 8.
• If NO, you must answer Question 3B.
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Answer this health question only if your acceptance is not guaranteed as defined
in Section 3.
4A. Within the past 2 years, did a medical professional provide treatment or advice to
you for any problems with your kidneys?
____________________
If you answered YES or NOT SURE to question 4A, we may follow up for additional information.
5A. Within the past 90 days, were you hospitalized as an inpatient (not including
overnight outpatient observation)?
____________________
5B. Are you currently being treated or living in any type of nursing facility other than an
assisted living facility?
____________________
5C. Has a medical professional told you that you have End-Stage Renal (Kidney) Disease
or that you require dialysis?
____________________
5
Answer these eligibility health questions only if your acceptance is not guaranteed
as defined in Section 3.
3
Is your acceptance guaranteed? (continued)
3B. Do you have guaranteed issue rights, as listed in the Guaranteed Acceptance section
of “Your Guide”?
____________________
• If YES, and you are applying for a Plan that is eligible for guaranteed acceptance as
defined in the Guaranteed Acceptance Section in “Your Guide”, skip directly to Section 9.
If YES and you are applying for a Plan that is NOT eligible for guaranteed acceptance as
defined in the Guaranteed Acceptance Section in “Your Guide”, continue to Section 4.
Note: Applicants age 50-64 who answer YES and are eligible for Medicare by reason of disability or ESRD may only
apply for the Plans shown in the Guaranteed Acceptance Section in “Your Guide”.
• If you answered NO to both questions in Section 3 and you are:
- age 65 or over, continue to Section 4.
- age 50-64 and eligible for Medicare by reason of disability or ESRD, you are NOT eligible to apply.
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6
Answer these health questions to determine your rate only if your acceptance is not
guaranteed as defi ned in Section 3.
6A. Within the past 2 years, did you have (as determined by a medical professional) or
were you diagnosed, treated, given medical advice or prescribed medications/refi lls for
any of the following conditions?
Atrial Fibrillation or Flutter
Artery or Vein Blockage
Peripheral Vascular Disease (PVD)
Cardiomyopathy
Congestive Heart Failure (CHF)
Coronary Artery Disease (CAD)
Chronic Obstructive Pulmonary Disease (COPD) or Emphysema
Chronic Kidney Disease
Diabetes, but only if you have circulation problems or Retinopathy
Cancer including Melanoma (but not other skin cancers), Leukemia and Lymphoma
Cirrhosis of the Liver
Macular Degeneration, but only if you have the wet form
Multiple Sclerosis
Rheumatoid Arthritis
• Systemic Lupus Erythematosus (SLE)
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
6B. Within the past 2 years, did you have (as determined by a medical professional) a
Heart Attack, Stroke, Transient Ischemic Attack (TIA) or Mini-Stroke?
____________________
If you answered YES to any question in Section 6, your rate will be the Level 2 rate.
See the enclosed “Cover Page – Rates.”
If you answered NOT SURE to any question, we may follow up for additional information.
____________________
____________________
____________________
____________________
____________________
____________________
5D. Within the past 2 years, did a medical professional tell you that you may need any of
the following that has NOT been completed?
hospital admittance as an inpatient
• joint replacement
• organ transplant
• surgery for cancer
• back or spine surgery
• heart or vascular surgery
____________________
Answering YES to any question in Section 5 will result in a denial of coverage.
If your health status changes in the future, allowing you to answer NO to all of the questions in this section, please
submit a new application at that time.
If you answered NOT SURE to any question in Section 5, we may follow up for additional information.
5
Answer these eligibility health questions only if your acceptance is not guaranteed
as defi ned in Section 3. (continued)
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Tell us about your tobacco usage only if your acceptance is not guaranteed as defined
in Section 3.
8A. At any time within the past 12 months, have you smoked tobacco cigarettes or used
any other tobacco product?
____________________
If you answered YES to Question 8A, your rate will be the tobacco rate. See “Cover Page - Rates.”
9
Your past and current coverage
Review the statements.
• You do not need more than one Medicare supplement policy.
• You may want to evaluate your existing health coverage and decide if you need multiple coverages.
• You may be eligible for benefits under Medicaid and may not need a Medicare supplement policy.
• If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare
supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You
must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid,
your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy) will be
reinstituted if requested within 90 days of losing Medicaid eligibility.
7
Tell us about your medical providers.
Provide the following information for all physicians that you have seen within the past two years. We may
follow up with your physicians for additional information.
_______________________________________________________________________________________
Primary Physician Phone #
_______________________________________________________________________________________
Address
_______________________________________________________________________________________
City State ZIP Code
_______________________________________________________________________________________
Specialist Name Specialty
_______________________________________________________________________________________
Diagnosis/Condition
_______________________________________________________________________________________
Specialist Name Specialty
_______________________________________________________________________________________
Diagnosis/Condition
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Your past and current coverage (continued)
PLEASE ANSWER ALL QUESTIONS.
To the best of your knowledge,
Questions about Medicaid
9A. Are you covered for medical assistance through the state Medicaid program?
(Medicaid is a state-run health care program that helps with medical costs for people
with low or limited income. It is not the federal Medicare program.) Note to applicant:
If you are participating in a “Spend-down Program” and have not met your “Share of
Cost”, answer NO to this question.
If YES, you must answer Questions 9B and 9C.
____________________
9B. Will Medicaid pay your premiums for this Medicare supplement policy?
____________________
9C. Do you receive any benefits from Medicaid other than payments toward your
Medicare Part B premium?
____________________
Questions about Medicare Advantage plans (sometimes called Medicare Part C)
9D. Have you had coverage from any Medicare plan other than original Medicare within
the past 63 days (for example, a Medicare Advantage plan, a Medicare HMO, or PPO)?
If YES, you must answer Questions 9E through 9H.
____________________
9E. Provide the start and end dates of your Medicare plan other than original Medicare.
If you are still covered under this plan, leave the end date blank.
Start Date
____________________
Month Day Year
End Date
____________________
Month Day Year
9F. If you are still covered under the Medicare plan other than original Medicare, do you
intend to replace your current coverage with this new Medicare supplement policy?
(When you receive confirmation that this Medicare Supplement plan has been issued,
you will need to cancel your Medicare Advantage Plan. Please contact your Medicare
Advantage insurer for instructions on how to cancel, using the customer service number
on the back of your ID card.)
____________________
9G. Was this your first time in this type of Medicare plan?
____________________
9H. Did you drop a Medicare supplement policy to enroll in the Medicare plan?
____________________
• If you are eligible for, and have enrolled in a Medicare supplement policy by reason of disability and you later become
covered by an employer or union-based group health plan, the benefits and premiums under your Medicare supplement
policy can be suspended, if requested, while you are covered under the employer or union-based group health plan. If you
suspend your Medicare supplement policy under these circumstances, and later lose your employer or union-based group
health plan, your suspended Medicare supplement policy (or, if that is no longer available, a substantially equivalent policy)
will be reinstituted if requested within 90 days of losing your employer or union-based group health plan.
• Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplement
insurance and concerning medical assistance through the state Medicaid program, including benefits as a Qualified Medicare
Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB).
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______________________________________________________________ __________________
Your Signature (required) Today’s Date (required)
Month Day Year
9
Your past and current coverage (continued)
Questions about Medicare supplement plans
9I. Do you have another Medicare supplement policy in force?
If so, what insurance company and what plan do you have?
Insurance Company: _________________________________________________
Policy: ___________________________________________________________
If YES, you must answer Question 9J.
____________________
9J. Do you intend to replace your current Medicare supplement policy with this policy?
____________________
Questions about any other type of health insurance coverage
9K. Have you had coverage under any other health insurance within the past 63 days
(for example, an employer, union, or individual plan)?
If YES, you must answer Questions 9L through 9N.
____________________
9L. If so, with what insurance company and what kind of policy?
Insurance Company:_______________________________________________
Policy:
9M. What are your dates of coverage under the other policy? Leave the end date blank
if you are still covered under the policy.
Start Date
____________________
Month Day Year
End Date
____________________
Month Day Year
9N. Are you replacing this health insurance?
____________________
10
Authorization and Verification of Application Information
Read carefully, and sign and date in the signature box.
• I declare the answers on this Application Form are complete and true to the best of my knowledge and belief and are
the basis for issuing coverage. I understand that this Application Form becomes a part of the insurance contract and that
if the answers are incomplete, incorrect or untrue, UnitedHealthcare Insurance Company may have the right to rescind my
coverage, adjust my premium, or reduce my benefits.
• Any person who includes any false or misleading information on an application for insurance coverage is subject to
criminal and civil penalties.
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My signature indicates I have read and understand all contents of this Application Form and have answered
all questions to the best of my ability.
______________________________________________________________ __________________
Your Signature (required) Today’s Date (required)
Month Day Year
Note: If you are signing as the legal representative (e.g., POA, Guardian, Conservator, etc.) for the applicant, please send a complete
copy of the appropriate legal documentation and check this box.
10
Authorization and Verification of Application Information (continued)
• I understand coverage, if provided, will not take effect until issued by UnitedHealthcare Insurance Company, the actual
premium is not determined until coverage is issued and that this Application Form and payment of the initial premium does
not guarantee coverage will be provided.
• I acknowledge receipt of the Guide to Health Insurance for People with Medicare and the Outline of Coverage.
If the Application Form is being completed through an Agent or Broker:
• I understand an agent or broker discussing Plan options with me is appointed by UnitedHealthcare Insurance Company,
and may be compensated based on my enrollment in a Plan.
• I understand that an agent or broker cannot change or waive any terms or requirements related to this Application Form
and its contents, underwriting, premium or coverage and cannot grant approval.
Authorization for the Release of Medical Information
I authorize UnitedHealthcare Insurance Company and its affiliates (“The Company”) to obtain from any health care provider,
licensed physician, medical practitioner, hospital, pharmacy, clinic or other medical facility, health care clearinghouse,
pharmacy benefit manager, insurance company, or other organization, institution or person, or The Company’s own
information, any data or records about me or my mental or physical health. I understand the purpose of this disclosure
and use of my information is to allow The Company to determine my eligibility for coverage and rate. I understand this
authorization is voluntary and I may refuse to sign the authorization. My refusal may, however, affect my eligibility to enroll
in the health plan or to receive benefits, if permitted by law. I understand the information I authorize The Company to obtain
and use may be re-disclosed to a third party only as permitted under applicable law, and once re-disclosed, the information
may no longer be protected by Federal privacy laws. I understand I may end this authorization if I notify The Company, in
writing, prior to the issuance of coverage. After coverage is issued, this authorization is not revocable. If not revoked, this
authorization is valid for 24 months from the date of my signature.
Please see “Your Guide” to determine if the following pre-existing condition waiting period applies to you.
I understand the plan will not pay benefits for stays beginning or medical expenses incurred during the first
3 months of coverage if they are due to conditions for which medical advice was given or treatment
recommended by or received from a physician within 3 months prior to the insurance effective date.
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Agent/Broker must complete the following information and include the notice of replacement coverage, if
appropriate, with this Application Form. All information must be complete or the Application Form will be returned.
1. List any other health insurance policies issued to the applicant:
_____________________________________________________________________________________
_____________________________________________________________________________________
2. List policies issued which are still in force:
_____________________________________________________________________________________
_____________________________________________________________________________________
3. List policies issued in the past 5 years which are no longer in force:
_____________________________________________________________________________________
_____________________________________________________________________________________
Agent Name (PLEASE PRINT) _______________________ ___ _____________________________________
First Name MI Last Name
______________________________________ ________________________ ___________________
Agent Signature (required) Agent ID (required) Today’s Date (required)
Month Day Year
___________________________________________________ _______________________________
Agent Email Address Agent Phone Number
______________________________________ ____________________________________________
Broker Name Broker ID
11
For Agent/Broker Use Only