Medicare Advantage Application

HDA Insurance Brokerage
Medicare Advantage Plan Individual Enrollment

Applicant Information

Medicare Card Information

Name: (Exactly as printed on card)
Medicare Claim Number:
Hospital: (Part A)	Effective Date:
Medical: (Part B)	Effective Date:
Comments:

Underwriting Questions

1.	Do you have End Stage Renal Disease (ESRD)?	Yes No
2.	Will you have other prescription drug coverage in addition to the plan applied for?	Yes No
3.	Are you a resident in a long-term care facility?	Yes No
4.	Are you enrolled in your State Medicaid program?	Yes No
5.	Do you or your spouse work?	Yes No