Establishing secure connection…Loading editor…Preparing document…

AARP Medicare Supplement Application Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

AARP Medicare Supplement Insurance Plans Application Form

Instructions: Fill in all requested information on this form and be sure to sign where indicated. Print clearly. Use CAPITAL letters.

1. Tell us about yourself

AARP Membership Number

Birthdate

Gender

First Name

MI

Last Name

Address Line 1

Address Line 2

City

ST

Zip

Phone

E-mail address (optional)

Please supply the following information, found on your Medicare card.

MEDICARE HEALTH INSURANCE

Name

Medicare Claim #

Hospital (Part A) Effective Date

Medical (Part B) Effective Date

Are both Medicare Parts A & B coverage active?

2. Tell us about your tobacco usage

If you have smoked cigarettes or used any tobacco product at any time within the past twelve months, darken this circle:

3. Choose your plan and effective date

Please indicate your plan choice below:

Requested Effective Date

4. Answer these questions to determine if your acceptance is guaranteed

4A. Did you turn age 65 in the last 6 months?

4B. Did you enroll in Medicare Part B within the last 6 months?

4C. Will your plan effective date be within 6 months after turning age 65 and enrolling in Medicare Part B?

4D. Have you lost or are you losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue?

5. Answer these health questions to determine if you are eligible for this coverage

5A. Do any of these apply to you? (kidney disease, dialysis, inpatient hospital stay in past 90 days)

5B. Has a medical professional recommended treatment not yet completed? (organ transplant, back surgery, joint replacement, etc.)

6. Tell us about your past and current coverage

6A. Did you turn age 65 in the last 6 months?

6B. Did you enroll in Medicare Part B in the last 6 months?

If yes, what is the effective date?

6C. Are you covered for medical assistance through the state Medicaid program?

6D. Will Medicaid pay your premiums for this Medicare supplement policy?

6E. Do you receive any benefits from Medicaid other than payments toward your Medicare Part B premium?

6F. If you had coverage from any Medicare plan other than original Medicare within the past 63 days, provide dates

Start

End

6G. If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new policy?

6H. Was this your first time in this type of Medicare plan?

6I. Did you drop a Medicare supplement policy to enroll in the Medicare plan?

6J. Do you have another Medicare supplement policy in force?

Company Name

Plan Name

6K. If so, do you intend to replace your current Medicare supplement policy with this policy?

6L. Have you had coverage under any other health insurance within the past 63 days?

Company Name

Policy Type

6M. What are your dates of coverage under the other policy?

Start

End

6N. Are you replacing this health insurance?

Your Signature – 1 (required)

Today’s Date

7. Authorization and Verification of Information

Please read carefully, and sign and date in the highlighted area below.

Your Signature – 2 (required)

Today’s Date

8. For Agent Use Only

Agent must complete the following; and if appropriate, the notice of replacement coverage included with this application.

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 five (5) years which are no longer in force:

Agent Name

MI

Last Name

Agent Phone Number

Agent Signature (required)

Agent ID (required)

Date

Automatic Payment Authorization Form

Please refer to the diagram below to obtain your bank routing information.

Name(s)

Address

City

State

Zip Code

Bank Name

Bank Routing No.

Bank Account No.

Account Type

Your Signature – 3

Today’s Date

Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage

Applicant’s Printed Name & Address

Applicant’s Signature

Date

Thank You For Applying For An AARP Medicare Supplement Insurance Plan

For your records:

You selected Plan

Based on the information you provided, your monthly premium

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the AARP Medicare Supplement Application Form Is

The AARP Medicare Supplement Application Form is the application used to enroll an individual in a Medicare Supplement (Medigap) insurance policy offered through AARP-affiliated carriers. It collects applicant identity, Medicare Part A and Part B information, plan selection, enrollment dates, prior coverage and replacement details, health underwriting answers, and payment instructions. The completed form serves as the legal record of the applicant's request for coverage and triggers insurer underwriting, premium calculation, and policy issuance processes.

Why this form matters

Completing the AARP Medicare Supplement Application Form correctly ensures accurate coverage start dates, accurate premium calculation, and reduces the risk of underwriting delays or application rescission.

Why this form matters

Who completes and relies on this application

Accurate completion reduces underwriting questions and speeds issuance, while missing data typically triggers follow-up requests or delays.

  • Applicants: Medicare beneficiaries or their authorized representatives completing enrollment and providing medical and Medicare details.
  • Agents/Brokers: Licensed producers who assist, sign agent sections, and submit applications to the carrier.
  • Carrier Underwriters: Insurance company staff who evaluate risk, determine eligibility, and issue policies.

Step-by-step: completing the application

Follow these steps in order to prepare and submit a complete AARP Medicare Supplement Application Form.

  • 01
    1. Gather documents: Collect Medicare card, ID, current policy documents, and medication list.
  • 02
    2. Complete sections: Enter applicant, Medicare, coverage selection, and health information fully.
  • 03
    3. Review and sign: Confirm answers, sign in required places, and date the form.
  • 04
    4. Submit to carrier: Send via carrier portal, agent upload, or permitted electronic submission method.

Core components of a professional application

A well-prepared AARP Medicare Supplement Application Form contains standard sections that carriers expect to receive complete and accurate.

Applicant Information

Full name, date of birth, mailing address, telephone, and email to establish identity and contact details for policy documents.

Medicare Details

Medicare Part A/B claim numbers and effective dates; required to confirm eligibility and coordinate benefits.

Plan Selection

Requested Medigap plan letter (A, B, G, N etc.), desired effective date, and premium payment method.

Health Underwriting

Medical history, current conditions, medications, and any recent hospitalizations used for underwriting determinations.

Replacement Disclosure

Statements regarding replacement of existing coverage and any required signed replacement notices per state rules.

Signatures and Acknowledgements

Applicant signature, agent signature, disclosures, and privacy authorization to finalize application and begin processing.

Required data elements and security notes

Applicant Name: Full legal name
Date of Birth: MM/DD/YYYY
Medicare ID: Part A/Part B claim number
Health History: Conditions and medications
Agent License: Producer name and license number
Signature: Signed and dated consent

Common mistakes to avoid

  • Using nicknames instead of the legal name can invalidate identity checks and slow processing.
  • Transposing Medicare claim numbers or dates leads to verification failures and manual follow-up.
  • Skipping replacement questions or misreporting prior coverage may trigger rescission or backdated premiums.
  • Failing to sign or date all required fields causes application rejection or processing delays.

Potential consequences of incorrect or incomplete applications

Rescission risk: Carrier may rescind coverage if material misstatements are discovered
Delayed coverage: Incomplete fields can postpone effective dates and benefits
Premium adjustments: Underwriting corrections may increase premium or change plan eligibility
Administrative fines: State regulators may levy administrative penalties for noncompliance
Tax implications: Incorrect payment reporting may affect tax forms or withholding
Privacy liability: Improper handling of PHI can trigger HIPAA obligations and penalties

How submission and processing typically flow

Applications follow a standard path from completion to policy issuance; understanding each step helps avoid delays.

  • Applicant completes form: Applicant or representative fills and signs required fields
  • Agent or carrier intake: Agent reviews and uploads to carrier or transmits via secure portal
  • Underwriting review: Carrier verifies Medicare and health answers and determines eligibility
  • Policy issuance: Accepted applications generate policy documents and billing instructions

Configuring an online submission workflow

When digitizing the application, set fields and routing to mirror the paper form and regulatory requirements.

Field Configuration
Applicant Name Required, single-line text
Medicare Number Required, masked numeric field
Health Questions Conditional fields shown if 'Yes' answers present
Signature Sign field with date and signer authentication

Technical considerations for electronic completion

Ensure the selected solution meets ESIGN/UETA standards and any state-specific identification or consent requirements before use.

  • File formats: PDF and DOCX supported
  • Authentication: Email, SMS, or stronger ID verification
  • Integrations: Carrier portals and CRM integration supported

eSignature vendor comparison for processing applications

Cost and feature needs vary by volume and required compliance. The table below compares common vendor entry points; signNow is listed first in accordance with platform data.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions and troubleshooting

Answers to common questions about completing and submitting the AARP Medicare Supplement Application Form.


Need help? Contact support

Explore Templates

Medco Health Medicare Part D Prior Authorization Form Humana Prior Authorization Form Express Scripts Prior Authorization Form Kentucky Cremation Authorization Form Tennessee HIPAA Release Form Envision RX Prior Authorization Form
be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.