Client Enrollment First Name Middle Name Last Name Home Phone Cell Phone DOB Email Physical Address ( No PO Boxes accepted ) City State Zip Code Mailing Address (only if different from physical address) City State Zip Code What is your Current Health Insurance Plan Name Medicare# Medicare Part A Date Medicare Part B Date Spouses Name Spouse's DOB First and Last Name of your Primary Care Doctor Emergency Contact Name Emergency Contact Phone How do you want to pay for your Monthly Plan Premium? Coupon BookSocial Security ( Only select this one if you have a Medicare Advantage or Prescription Drug Plan ) Banking Information if you want Auto Payment : Bank Name Bank Routing Number Bank Account Number Δ
