Florida's Trusted Health & Medicare Insurance Broker

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Step 1 — Medicare Information

Medicare numbers and effective dates.

AARP Member Number

Medicare Number *

Medicare Part A Effective Date *

Medicare Part B Effective Date *

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Step 2 — Personal Information

Basic details about the applicant.

First Name *

Middle Initial

Last Name *

Street Address *

City *

County

State *

ZIP Code *

Phone Number *

Email Address *

Date of Birth *

Gender *

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Step 3 — Plan Choice

Select your desired Medicare Supplement plan.

Select Plan Option

Plan F Plan G Plan N

Requested Effective Date

Active Part A & B on start date? *

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Step 4 — Eligibility Questions

Answer these questions to confirm eligibility.

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Step 5 — Agent / Broker Use Only

Insurance history as issued by broker.

Other health insurance policies issued to applicant

Policies still in force

Lapsed policies in past 5 years

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Step 6 — Bank Account Information

Used for premium payments.

Account Holder Name

Bank Name

Account Type

Routing Number

Account Number

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Step 7 — Notes & Enrollment Details

Final remarks and office enrollment info.

Additional Notes

PDP Details

Premium Amount

Enrollment Date

Confirmation #

By submitting, you certify that all information provided is accurate and complete.

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