AARP Medicare Supplement Application - Colorado Health Agents

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IMPORTANT • Please refer to the diagram below to obtain your bank routing information. • Be sure to attach a voided check from the checking account you wish to use. VOID We look forward to continuing to serve you. Monthly withdrawal amounts will be for the total household payment due each month. This will include premiums for a spouse or other member(s) of the household on the same membership account. This authority is active until UnitedHealthcare and the BANK receive notice from me to end withdrawals in enough time to give UnitedHealthcare and the BANK a reasonable opportunity to act on it. I have the right to stop payment of a withdrawal by giving notice to the BANK in such time as to give the BANK a reasonable opportunity to act upon it. I understand such action may make the health care insurance coverage past due and subject to cancellation. Member Name________________________________________ Member # _____________ Bank Acct Holder’s Name (if different) ___________________________________________ Bank Acct Holder’s Signature ________________________________ Date _____________ Please do not write in the space below. For company use only. 0000001 0000033 0066 0074 UMS1129 01 L
Save $24 a year with the Electronic Funds Transfer (EFT) service The easiest way to pay. More than 2.5 million AARP members nationwide enjoy the convenience of the automatic payments option. With EFT, your monthly payment will automatically be deducted from your checking or savings account. Also, you’ll save $2.00 off the total monthly rate for your household. In addition to saving up to $24.00 a year: • You’ll save on the cost of checks and rising postal rates. • You don’t have to take time to write a check each month. • You don’t have to worry about mailing a payment if you travel or become ill, because your payment is always deducted on or about the fifth day of each month. Sign Up in Two Easy Steps 1. Complete both sides of the Automatic Payment Authorization Form below. Return it with the application and be sure to keep a copy for your records. 2. Include a voided check for the checking account from which you want your payments withdrawn. The information on your check is needed to process your request for EFT. Do not send a deposit slip or cancelled check. Your Automatic Payments Effective Date If you are submitting this EFT form with your enrollment application, your automatic payments start date will be equal to your plan effective date. A letter will be sent to confirm this and will include the amount of your withdrawal. Please note that if your coverage is effective in the future or your account is paid in advance, EFT withdrawals will begin for the next payment due. If your account is effective in the past or is past due, a letter will be sent that explains how to make the payment that is due. BA9957A (10-12) Cut along the dotted line. AUTOMATIC PAYMENT AUTHORIZATION FORM I allow UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company of New York, for New York residents), hereafter named UnitedHealthcare, to take monthly withdrawals, for the then-current monthly rate, from the account named on this form. I also allow the named banking facility (BANK) to charge such withdrawals to this account. Member Name __________________________ Member Address_________________________ City ___________________________________ State ________________ Zip Code __________ Bank Name _____________________________ Bank Routing No. ________________________ Bank Account No. ________________________ Account Type: Checking Savings (statement savings only) The reverse side of this form must also be completed. 0000001 0000034 0067 0074 UMS1129 01 L
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Colorado AARP Medicare Supplement I
Page 3 and 4:
Instructions Page Please Read Befor
Page 5 and 6:
Hello, Thank you for your interest
Page 7 and 8:
Your Plans and Rates AARP ® Medica
Page 9 and 10:
Cover Page - Rates for Colorado - A
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Page 13 and 14:
Page 15 and 16: Cover Page - Rates for Colorado - A
Page 25 and 26: Outline of Coverage | UnitedHealthc
Page 27 and 28: Your Guide to AARP Medicare Supplem
Page 51 and 52: Your Exclusive Member Services. Get
Page 53 and 54: Enrollment Checklist In the followi
Page 55 and 56: Application Form AARP ® Medicare S
Page 57 and 58: 5 Answer these health questions to
Page 59 and 60: 7 Tell us about your past and curre
Page 61 and 62: 8 Authorization and Verification of
Page 63 and 64: AARP membership offers so much for
Page 65: Save $24 a year with the Electronic
Page 69 and 70: NOTICE TO APPLICANT REGARDING REPLA
Page 71 and 72: 0000001 0000036 0071 0074 UMS1129 0
Page 73 and 74: Thank You for Applying for an AARP
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AARP Medicare Supplement Application - Colorado Health Agents

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