Home Oce Use Only
243655.0923ILUWMSAPP-REV092023
Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC),
an Independent Licensee of the Blue Cross and Blue Shield Association
Application for Medicare Supplement Insurance Plan
Instructions
1. To be considered for coverage, you must have Medicare Parts A and B, reside in Illinois, and be:
a) age 65 or over or b) applying within 6 months of your Medicare Part B eective date.
2.
If submitting a paper application, please complete in ink. Be sure to sign and date on the appropriate
line(s) on pages 6, 7 and 12. Send no money now! No payment is due until you have a chance to review your
policy and make sure the coverage is right for you.
Plan Selection Check one box to apply for a Medicare Supplement Insurance Plan.
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Plan A
Secure
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Plan F
Secure
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Plan F Plus
Secure
Plan G Secure
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Standard
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Medicare Select
Plan G Plus Secure
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Standard
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Medicare Select
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Plan N
Secure
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Plan N
Plus
Secure
Requested Policy Eective Date:
Note: Plan F Secure is only available if you are Medicare-eligible prior to 2020.
Applicant Information
Name (First) (Middle) (Last)
Home Address (No P.O. Boxes) City State
IL
ZIP
Correspondence / Billing Address City State ZIP
Primary Phone Secondary Phone Age Date of Birth
Gender
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Male
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Female
Social Security Number Email Address
Preferred Method of Contact:
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Mail
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Phone
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Email
Tobacco Use
Blue Cross and Blue Shield of Illinois (BCBSIL) denes a tobacco user as a person who is using or has used
any tobacco products in the last 6 months prior to the date of enrollment for a plan. This includes but is not
limited to cigarettes, cigars, smokeless tobacco products, electronic cigarettes, dissolvable tobacco products,
and vaping.
Within the past 6 months, have you used tobacco 4 or more times per
week on average, excluding religious or ceremonial uses?
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Yes
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No
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BlueCross BlueShield
of
Illinois
Underwritten
by
HCSC
Insurance
Services
Company
— 2 —
Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC),
an Independent Licensee of the Blue Cross and Blue Shield Association
243655.0923ILUWMSAPP-REV092023
Applicant Name:
Premium Discounts
A BCBSIL Medicare Supplement premium discount may be available. Eligibility criteria are described below.
If you are eligible for a discount, the discount will be applied to your next bill and remain in eect as long as
you are enrolled in your BCBSIL Medicare Supplement plan. Discounts cannot be combined; only one type of
discount per member is permitted.
Household Discount
You may be eligible for a discount if you reside with a spouse or civil union/domestic partner or have resided
with as many as three adults age 60 or older for the last 12 months. Applies to BCBSIL Medicare Supplement
policies issued with an eective date on or after May 1, 2019. The discount is 10%.
Are you applying for this discount?
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Yes
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No
Continue with Blue
℠
Discount
You may be eligible for a discount if you enrolled in a BCBSIL Medicare Supplement policy issued with an
eective date on or after April 1, 2022 and you were enrolled in a Blue Cross and Blue Shield commercial group
or individual health insurance coverage plan and that coverage was within one year of your BCBSIL Medicare
Supplement policy becoming eective. The discount is 7%.
Are you applying for this discount?
■
Yes
■
No
If yes, provide your previous commercial group or individual coverage subscriber ID:
Blue Family Discount
℠
You may be eligible for a discount if you enrolled in a BCBSIL Medicare Supplement policy issued with an
eective date on or after April 1, 2024 and you meet the criteria for both the Household Discount AND the
Continue with Blue Discount. The discount is 12%.
Are you applying for this discount?
■
Yes
■
No
If yes, provide your previous commercial group or individual coverage subscriber ID:
— 3 —
Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC),
an Independent Licensee of the Blue Cross and Blue Shield Association
243655.0923ILUWMSAPP-REV092023
Applicant Name:
Payment Option (Select one payment option)
1. Premium deducted from bank account (choose one):
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Checking
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Savings
Account holder name:
Bank name:
Bank routing number: Bank account number:
Account Owner Signature (if dierent than applicant)
Bank Draft Authorization Agreement
By signing this application, I request and authorize BCBSIL and/or its designee to obtain payment of amounts
becoming due by initiating charges to my account in the form of checks, share drafts, or electronic debit
entries, and I request and authorize the nancial institution named below to accept and honor the same to
my account.
I understand that this request for coverage is not an employer group health plan and is not intended, in
any way, to be an employer sponsored health insurance plan. I certify the employer(s) of those applying for
coverage will not contribute any part of the premium or provide reimbursement for any part of the premium
now or in the future.
I also understand that both the nancial institution and BCBSIL reserve the right to terminate this payment
program and/or my participation therein. To make changes to my nancial institution I understand that I will
need to provide at least 10 days advanced notice to BCBSIL by telephone prior to a scheduled withdrawal
date. I authorize BCBSIL to deduct the premium payments from my checking or savings account. If the draft
date falls on a non-business day or a holiday, the premium payment will be deducted from my account on
the next business day.
2.
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Premium to be billed by mail
3. I will pay my premium:
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Monthly
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Quarterly
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Semi-Annually
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Annually
Medicare Beneciary Identier
Please copy the Medicare Beneciary Identier from your red, white and blue Medicare Card.
This number must be provided to us to complete your application process.
Medicare Beneciary Identier
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Part A Eective Date: Part B Eective Date:
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— 4 —
Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC),
an Independent Licensee of the Blue Cross and Blue Shield Association
243655.0923ILUWMSAPP-REV092023
Applicant Name:
Consumer Protection Information
If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying
you were eligible for guaranteed issue of a Medicare Supplement insurance policy, or that you had certain
rights to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare Supplement
Insurance Plans. Please include a copy of the notice from your prior insurer with your application.
Please answer all questions. Please mark Yes or No below with an “X” to the best of your knowledge.
1. Did you turn age 65 in the last 6 months?
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Yes
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No
2. Did you enroll in Medicare Part B in the last 6 months?
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Yes
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No
If yes, what is the eective date? Eective Date:
3. Are you covered for medical assistance through the state Medicaid program?
NOTE TO APPLICANT: If you are participating in a “Spend-Down Program” and
have not met your “Share of Cost,” please answer NO to this question.
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Yes
■
No
a. If yes, will Medicaid pay your premiums for this Medicare Supplement policy?
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Yes
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No
b. If yes, do you receive any benets from Medicaid OTHER THAN
payments toward your Medicare Part B premium?
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Yes
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No
4. If you had coverage from any Medicare plan other than Original Medicare
within the past 63 days (for example, a Medicare Advantage plan, or a
Medicare HMO or PPO), ll in your start and end dates.
(If you are still covered under this plan, leave “End Date” blank.)
Start Date: End Date:
a. If you are still covered under the Medicare plan, do you intend to replace
your current coverage with this new Medicare Supplement policy?
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Yes
■
No
b. Was this your rst time in this type of Medicare plan?
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Yes
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No
c. Did you drop a Medicare Advantage policy to enroll in the Medicare plan?
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Yes
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No
5. Do you have another Medicare Supplement policy in force?
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Yes
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No
a. If so, with what company, and what plan do you have?
b. If so, do you intend to replace your current Medicare Supplement policy
with this policy?
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Yes
■
No
6. Have you had coverage under any other health insurance within the
past 63 days?
■
Yes
■
No
a. If so, with what company, and what kind of policy?
(For example, an employer, union, or individual plan)
b. What are your dates of coverage under the other policy?
(If you are still covered under the other policy, leave “End Date” blank.)
Start Date: End Date:
— 5 —
Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC),
an Independent Licensee of the Blue Cross and Blue Shield Association
243655.0923ILUWMSAPP-REV092023
Applicant Name:
Statements
1. You do not need more than one Medicare Supplement policy.
2. If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need
more than one type of coverage in addition to your Medicare benets.
3. You may be eligible for benets under Medicaid and may not need a Medicare Supplement policy.
4. If, after purchasing this policy, you become eligible for Medicaid, the benets and premiums under
your Medicare Supplement policy can be suspended, if requested, during your entitlement to benets
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.
*
5. 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 benets 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.
*
6. Counseling services may be available in your state to provide advice concerning your purchase of a
Medicare Supplement Insurance Plan and concerning medical assistance through the state Medicaid
program, including benets as a Qualied Medicare Beneciary (QMB) and a Specied Low-Income
Medicare Beneciary (SLMB).
For information on Medicaid eligibility, call your local Social Security oce. For questions on Medicare
Supplement Insurance Plans, call 1-800-MEDICARE (1-800-633-4227).
7.
Under Illinois Senate Bill 147, if you are between the ages of 65 and 75 and have enrolled in a Medicare
Supplement policy, you are entitled to an annual open enrollment period lasting 45 days starting with your
birthday. During this time, you will be able to purchase a BCBSIL Medicare Supplement policy that oers
benets equal to or lesser than those provided by your previous coverage. This policy cannot be denied or
conditioned, nor discriminate in the pricing of coverage because of health status, claims experience, receipt
of health care, or a medical condition of the individual. Purchasing a new Medicare Supplement policy will
require reapplying within the 45 day window.
*
If the Medicare Supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare
Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but
will otherwise be substantially equivalent to your coverage before the date of the suspension.
Questions?
Call us at our Customer Service toll-free number 877-384-9297,
call your insurance agent at the number listed on page 8, or visit
www.bcbsil.com.
— 6 —
Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC),
an Independent Licensee of the Blue Cross and Blue Shield Association
243655.0923ILUWMSAPP-REV092023
Proxy Statement
The undersigned hereby appoints the Board of Directors of HCSC Insurance Services Company, a Mutual
Legal Reserve Company, or any successor thereof (“HISC”), with full power of substitution, and such persons
as the Board of Directors may designate by resolution, as the undersigned’s proxy to act on behalf of the
undersigned at all meetings of members of HISC (and at all meetings of members of any successor of HISC)
and any adjournments thereof, with full power to vote on behalf of the undersigned on all matters that may
come before any such meeting and any adjournment thereof. The annual meeting of members shall be
held each year in the corporate headquarters (300 E Randolph St., Chicago, IL 60601) on the last Tuesday of
October at 12:30 p.m. Special meetings of members may be called pursuant to notice mailed to the member
not less than 30 nor more than 60 days prior to such meetings. This proxy shall remain in eect until revoked
in writing by the undersigned at least 20 days prior to any meeting of members, or by attending and voting in
person at any annual or special meeting of members.
Applicant Signature (optional):
Print Your Name as You Signed It: Date:
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— 7 —
Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC),
an Independent Licensee of the Blue Cross and Blue Shield Association
243655.0923ILUWMSAPP-REV092023
Applicant Name:
Acknowledgements and Signature
1. I hereby apply for coverage and request a policy to review for the Medicare Supplement policy indicated.
2. I understand that once my rst premium payment is received, I will be covered as of the date shown on
the Company identication card. Once coverage begins, I understand I have 30 days to return my policy
materials and receive a full refund for any premiums paid. Services are covered only when received on or
after the eective date of the policy chosen, except in the case of inpatient services, where the admission
must occur on or after the eective date to be covered.
3. I hereby declare that the statements and answers on this application, including but not limited to those
relating to age and medical history, are true and complete to the best of my knowledge and belief. I agree
that the Company, believing them to be true, shall rely and act upon them accordingly. I hereby agree to
furnish any additional information, if requested.
4. I understand that the Company has the right to reject my application. If the Company rejects my application,
I will be notied in writing. If this application is accepted, it will become part of the insurance policy.
5. I acknowledge that I have read and understand the Statements section regarding Medicare Supplement
coverage. If eligible for a Medicare Select Plan, I have also read and understand the statements regarding
Medicare Select as described in the Outline of Coverage. WARNING: Any person who knowingly, and with
intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy
containing any false, incomplete or misleading information may be guilty of a felony.
6. I acknowledge that any agent is acting on my behalf for purposes of purchasing the insurance, and that if
the Company accepts this application and issues an individual policy, the Company may pay the agent a
commission and/or other compensation in connection with the issuance of such individual policy.
7. I acknowledge if I desire additional information regarding any commissions or other compensation paid to the
agent by the Company in connection with the issuance of the individual policy, I should contact the agent.
8. I acknowledge that I have received a copy of the Medicare Supplement Buyer’s Guide.
9.
■
Outline of Coverage: I acknowledge receipt of Outline of Coverage.
Signature Required
Must be signed in ink and dated to avoid processing delays. For Power of Attorney and Legal Guardianships,
be sure to submit copies of the court documents with the application.
Applicant: Date:
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— 8 —
Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC),
an Independent Licensee of the Blue Cross and Blue Shield Association
243655.0923ILUWMSAPP-REV092023
Applicant Name:
Agent Information (If Applicable)
The following information is to be lled out by an agent, if Applicant is purchasing coverage through an agent.
Please list any other health insurance policies or coverages sold to the applicant which are still in force:
Please list any other health insurance policies or coverages sold to the applicant within the last ve (5) years
which are no longer in force:
I have rearmed that the information supplied on this application is accurate and complete.
Agent Signature: Date:
Print Name: Broker Code:
Agency Name (If Applicable): Agent Phone:
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— 9 —
Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC),
an Independent Licensee of the Blue Cross and Blue Shield Association
243655.0923ILUWMSAPP-REV092023
Applicant Name:
PLEASE CONTINUE ON THIS PAGE IF YOU ARE NOT NEWLY
ELIGIBLE TO ENROLL IN MEDICARE DUE TO AGE OR DISABILITY.
Guaranteed Issue Eligibility
Please mark Yes or No to questions 1–8 with an “X.” If you answer “Yes” to any and if you are applying before
the 63rd day after your coverage terminated, you are eligible for guaranteed issuance of this Medicare
Supplement policy. If you are eligible for guaranteed issuance of this policy, do not complete the Health
History/Medical Questions that start on page 11. Proceed to page 12 and sign the Medical Authorization.
Have any of the following events listed below, and on the next page, occurred?
1.
The individual is enrolled under an employee welfare benet plan that provides health
benets that supplement the benets under Medicare, and the plan terminates, or
the plan ceases to provide all such supplemental health benets to the individual; or
the individual is enrolled under an employee welfare benet plan that is primary to
Medicare and the plan terminates or the plan ceases to provide all health benets to
the individual because the individual leaves the plan.
■
Yes
■
No
2. The individual is enrolled with a Medicare Advantage organization under a Medicare
Advantage plan under Part C of Medicare, and any of the following circumstances
apply, or the individual is 65 years of age or older and is enrolled with a Program of
All-Inclusive Care for the Elderly (PACE) provider under section 1894 of the Social
Security Act, and there are circumstances similar to the following that would permit
discontinuance of the individual’s enrollment with such provider if such individual
was enrolled in a Medicare Advantage plan: (A) the certication of the organization
or plan has been terminated; or (B) the organization has terminated or otherwise
discontinued providing the plan in the area in which the individual resides; (C) the
individual is no longer eligible to elect the plan because of a change in the individual’s
place of residence or other change in circumstances specied by the Secretary, but
not including termination of the individual’s enrollment on the basis described in
section 1851 (g)(3)(B) of the Social Security Act (where the individual has not paid
premiums on a timely basis or has engaged in disruptive behavior as specied in
standards under section 1856), or the plan is terminated for all individuals within
a residence area; (D) the individual demonstrates, in accordance with guidelines
established by the Secretary, that: (i) the organization oering the plan substantially
violated a material provision of the organization’s contract under U.S.C. Title 42,
Chapter 7, Subchapter XVIII, Part D in relation to the individual, including the failure
to provide an individual on a timely basis medically necessary care for which benets
are available under the plan or the failure to provide such covered care in accordance
with applicable quality standards; or (ii) the organization, or agent or other entity
acting on the organization’s behalf, materially misrepresented the plan’s provisions
in marketing the plan to the individual; or (E) the individual meets such other
exceptional conditions as the Secretary may provide.
■
Yes
■
No
— 10 —
Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC),
an Independent Licensee of the Blue Cross and Blue Shield Association
243655.0923ILUWMSAPP-REV092023
Applicant Name:
Guaranteed Issue Eligibility
3. The individual is enrolled with an entity listed in subparagraphs (A)-(D) of this
paragraph and enrollment ceases under the same circumstances that would permit
discontinuance of an individual’s election of coverage under paragraph (2) of this
subsection: (A) an eligible organization under a contract under section 1876 of
the Social Security Act (Medicare cost); (B) a similar organization operating under
demonstration project authority, eective for periods before April 1, 1999; (C) an
organization under an agreement under section 1833(a)(1)(A) of the Social Security Act
(health care prepayment plan); or (D) an organization under a Medicare Select policy;
and
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Yes
■
No
4. The individual is enrolled under a Medicare Supplement policy and the enrollment
ceases because: (A) of the insolvency of the issuer or bankruptcy of the nonissuer
organization; or of other involuntary termination of coverage or enrollment under
the policy; (B) the issuer of the policy substantially violated a material provision of
the policy; or (C) the issuer, or an agent or other entity acting on the issuer’s behalf,
materially misrepresented the policy’s provisions in marketing the policy to the
individual;
■
Yes
■
No
5. The individual was enrolled under a Medicare Supplement policy and terminates
enrollment and subsequently enrolls, for the rst time, with any Medicare Advantage
organization under a Medicare Advantage plan under part C of Medicare, any eligible
organization under a contract under section 1876 of the Social Security Act (Medicare
cost), any similar organization operating under demonstration project authority, any
PACE provider under section 1894 of the Social Security Act, or a Medicare Select
policy; and the subsequent enrollment is terminated by the individual during any
period within the rst 12 months of such subsequent enrollment (during which the
individual is permitted to terminate such subsequent enrollment under section 1851
(e) of the Social Security Act); or
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Yes
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No
6. The individual, upon rst becoming enrolled in Medicare part B for benets at age
65 or older, enrolls in a Medicare Advantage plan under part C of Medicare, or with a
PACE provider under section 1894 of the Social Security Act, and disenrolls from the
plan no later than 12 months after the eective date of enrollment.
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Yes
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No
7. The individual enrolls in a Medicare Part D plan during the initial enrollment period
and, at the time of enrollment in Part D, was enrolled under a Medicare Supplement
policy that covers outpatient prescription drugs and the individual terminates
enrollment in the Medicare Supplement policy and submits evidence of enrollment in
Medicare Part D along with the application for a policy described in subsection (c)(4) of
this section.
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Yes
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No
8. The individual loses eligibility for health benets under Title XIX of the Social Security
Act (Medicaid).
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Yes
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No
— 11 —
Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC),
an Independent Licensee of the Blue Cross and Blue Shield Association
243655.0923ILUWMSAPP-REV092023
Applicant Name:
Health History / Medical Questions
Note: If you are eligible for Guaranteed Issue or in your Open Enrollment period,
you are not required to answer the following health questions. (Continue to page 12.)
Please answer the following health history questions.
1. What is your height? Ft. In.
2. What is your weight? Lbs.
3. When you rst became eligible for Medicare, was it either because of disability or
end stage renal disease?
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Yes
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No
4. Within the past 3 years, have you been diagnosed, treated, hospitalized or recommended
for treatment, including drug therapy, by a physician or any other provider for any of the following:
a. Diabetes with amputation, loss of sight or complications aecting the kidney?
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Yes
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No
b. Organ or tissue transplant (except cornea)?
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Yes
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No
c. Cancer (excluding basal cell or squamous cell cancer of the skin)?
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Yes
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No
d. Leukemia or Hodgkin’s disease?
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Yes
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No
e. Stroke, Transient Ischemic Attack (TIA), or mini-stroke?
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Yes
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No
f. Alzheimer’s disease, senility, dementia or brain disorder?
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Yes
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No
g. Parkinson’s disease?
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Yes
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No
h. Carotid artery disease, heart attack, or heart by-pass surgery or angioplasty?
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Yes
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No
i. Congestive heart failure or heart valve replacement?
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Yes
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No
j. Nephritis or kidney failure?
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Yes
■
No
k. Cirrhosis of the liver or Hepatitis C?
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Yes
■
No
l. Multiple Sclerosis or neuromuscular disorders?
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Yes
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No
m. Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease)?
■
Yes
■
No
n. Respiratory or lung disease requiring use of oxygen?
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Yes
■
No
o. Alcohol or chemical dependency?
■
Yes
■
No
5. Within the past 3 years, have you been treated for or diagnosed by a member of the
medical profession as having Acquired Immune Deciency Syndrome (AIDS), AIDS
Related Complex (ARC) or human immunodeciency virus (HIV) infection?
■
Yes
■
No
6. Within the past 2 years, have you been advised to have kidney dialysis, joint
replacement, or surgery for the heart, arteries or intestines that has not yet been done?
■
Yes
■
No
7. Within the past 2 years, have you been hospitalized 2 or more times, or have you been
conned to a nursing home or other care facility for 14 or more days?
■
Yes
■
No
STOP
— 12 —
Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC),
an Independent Licensee of the Blue Cross and Blue Shield Association
243655.0923ILUWMSAPP-REV092023
Applicant Name:
Health History / Medical Questions
8. Are you currently conned, or has connement been recommended within the next
6 months to a bed, hospital, nursing facility, or other care facility, or do you need the
assistance of a wheelchair or a home health care agency?
■
Yes
■
No
9. Do you need or receive help from any other person to perform any of the activities
below because of health or physical diculty?
• Taking Medications
• Eating
• Walking
• Bathing
• Dressing
• Toileting
• Moving from place to place in your home
• Getting in and out of bed or chairs
■
Yes
■
No
Medical Authorization
I authorize any medical professional, hospital, clinic or other medical or medically related facility,
governmental agency or other person or rm, to disclose to the Company or their authorized representative,
information, including copies of records, concerning advice, care or treatment provided to me, including
and without limitation, information relating to the use of drugs or alcohol. I also authorize the release of
information relating to mental illness. In addition, I authorize the Company to review and research its own
records for information.
I understand my authorization is voluntary and that such information will be used by the Company for the
purpose of evaluating my application for health insurance. Further, I understand that my authorization is
required for the Company to consider my application and to determine whether or not an oer of coverage
will be made. No action will be taken on my application without my signed authorization. I understand
information obtained with my authorization may be re-disclosed by the Company as permitted or required by
law and no longer protected by the federal privacy laws. I understand that I or any authorized representative
will receive a copy of this authorization upon request. This authorization is valid from the date signed and
shall remain valid for 24 months, unless revoked by me in writing, which I may do at any time by sending a
written request to the Company. Any revocation will not aect the activities of the Company prior to receipt of
the revocation.
SIGNATURE REQUIRED
Must be signed in ink and dated to avoid processing delays.
Applicant: Date:
Questions?
Call us at our Customer Service toll-free number 877-587-6616,
call your insurance agent at the number listed on page 8, or visit
www.bcbsil.com.
/ /
— 13 —
Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC),
an Independent Licensee of the Blue Cross and Blue Shield Association
243655.0923ILUWMSAPP-REV092023
Applicant Name:
Checklist
■
Have you signed on pages 6, 7, and 12?
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If you’re working with an agent, has the agent signed on page 8 (if applicable)?
■
Have you answered all Health History / Medical Questions on pages 11–12?
■
Have you made sure your requested eective date on page 1 is the 1st through the 28th of the month?
Return to your agent or mail this application to:
Blue Medicare Supplement
℠
c/o Member Services
PO Box 3388
Scranton, PA 18505
Medicare Supplement insurance plans are oered by Blue Cross and Blue Shield of Illinois, which refers to HCSC
Insurance Services Company (HISC), an Independent Licensee of the Blue Cross and Blue Shield Association.
