Medicare Supplement Insurance

Apply for Medicare Supplement Insurance from QualChoice using our online application.

Who can apply:

1. Age 65 or older or qualified for Medicare due to disability.
2. Arkansas resident in one of the counties we serve Select Date Above
3. Have both Medicare Part A and Medicare Part B

Before you start:

Make sure you have the following information before starting the online application.

• Date of Birth
• Social Security Number
• Medicare Card
• Height and Weight
• Medical History
  • names & addresses of all physicians, hospitals, and facilities
  • date of any diagnosis or treatment
  • current medical condition
• Medications History
  • names of prescription drugs
  • time frame taken
  • dosage
  • name & address of the prescribing physician

Policy effective dates:

The policy effective date will be the 1st of the month after your application is approved and processed.

Effective date of coverage cannot be:

• Prior to your Medicare Part A and Part B effective dates
• Prior to your termination from a Medicare Advantage Plan
• Prior to your application submission date

Important information:

Depending on your medical history, the online process could take from 15 to 45 minutes. You will not be able to save your information and come back, so make sure you have enough time to complete the entire application. If there is no activity after 30 minutes, your session will end and the information you entered may be lost.

In answering the questions in this application, do not include any family medical history or information related to genetic testing, services or counseling. Also, do not include any information regarding a genetic disease that has not manifested itself or has been diagnosed principally on genetic information.

Note:

MediQ65 Medicare Supplement Insurance is underwritten by QualChoice Life and Health Insurance Company, Inc., which is refered to as 'The Company', 'we', 'us' and 'our' in this application.

This application is a legal document, which will become part of your contract if you are approved for coverage. It is very important that you provide all requested information and that it is accurate.

The information provided here will be used and disclosed only as permitted by our Notice of Privacy Practices.

For more information about Medicare and Medicare Supplement Insurance Policies:

• Senior Health Insurance Information Program (SHIIP)

  State of Arkansas

  SHIIP provides free one-on-one counseling, education, and information to individuals with Medicare of all ages.

  800.224.6330 or 501.371.2782

• Medicare — 24 hours a day, 7 days a week

  1.800.633.4227 (1.800.MEDICARE)

  TTY/TDD users call 1.877.468.2048

• Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare

For Brokers:

Before this form can be processed, the agent/broker’s current AHIP certification must be on file with QualChoice. In addition, the agent/broker must be appointed with QualChoice.