Applications

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Missing AARP Membership Number

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

Prior to continuing with this request, please ensure your request is being submitted for the correct individual. Please verify that your client's name and AARP Membership Number listed above is accurate.

If an AARP Membership Number is not displaying above, please provide the Application #

Application #

All fields marked with an * are required.

Enter the AARP Membership Number *

Please enter a valid number

Where can an applicant find this?

Applicants can find their AARP Membership Number on the front of their AARP card located to the right of the expiration date. See image below.

Select the Person to Whom the AARP Membership Number Applies *

Please Select One

If You Chose Other, How Are You Related to the AARP Membership Holder? *

Please enter required data

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

By clicking the Submit button below, you the agent/agent's representative agree the information is accurate and was provided by the applicant, and you are submitting this change request on their behalf.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

Upon clicking on the Close button or the "X" in the upper right corner, you will be returned to the Service Request screen. From there you can choose another request for the same client or continue with the other activities.

Missing Guaranteed Issue Documents

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

All fields marked with an * are required.

Please upload a copy of the missing guaranteed issue documentation*

Examples can include documents such as Carrier termination notice, Employer letter, ANOC, etc.

Drag and drop your file here, or upload your documents

Only accepts PDF, JPG, JPEG, PNG format.
Upload up to 5 documents, max upload cannot exceed 9.5MB

Your documents

{{file.size}} MB

Remove

Your total document size maximum has exceeded 9.5MB.

You have uploaded too many documents. The maximum accepted is 5 documents.

You have attached an incorrect file format. Files must be a PDF, JPG, JPEG or PNG.

Your file did not upload successfully. Please try again.

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

By clicking the Submit button below, you the agent/agent's representative agree the information is accurate and was provided by the applicant, and you are submitting this change request on their behalf.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Error: Document upload was not successful because the file(s) contain a virus or is otherwise infected. We are unable to process the change request. Please contact the PHD at 1-888-381-8581 for direction.

Missing Legal Forms (FL, IL, KY, OH)

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

All fields marked with an * are required.

Please upload the Florida, Illinois, Kentucky or Ohio state-specific legal form *

Drag and drop your file here, or upload your documents

Only accepts PDF, JPG, JPEG, PNG format.
Upload up to 5 documents, max upload cannot exceed 9.5MB

Your documents

{{file.size}} MB

Remove

Your total document size maximum has exceeded 9.5MB.

You have uploaded too many documents. The maximum accepted is 5 documents.

You have attached an incorrect file format. Files must be a PDF, JPG, JPEG or PNG.

Your file did not upload successfully. Please try again.

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

By clicking the Submit button below, you the agent/agent's representative confirm the agent completed the legal enrollment form with the applicant and agree the information is accurate.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Missing Medicare Number

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

Please complete the required fields with the applicant.

All fields marked with an * are required.

Enter the Missing Medicare ID Number *

Do not include hyphens or spaces when entering the Medicare number.

Please enter required data. Please enter a valid Medicare ID Number.

Where can an applicant find this?

Applicants can find their AARP Medicare Number on the front of their Medicare card located under their name. See image below.

Inform your client of the following

You will receive a change request to sign via email; therefore, an email address will be required for you. By providing your email address, you are agreeing to apply your electronic signature as approval for this change.
While signing with Remote Signature, you will be using Adobe Sign, a trusted company that provides electronic signing for documents.
You will need to review and sign the change request within 24 hours of when I initiate this task. You are not required to sign and agree to the requested change. If the information is not accurate or you have additional questions, do not sign the form and please contact me.
If you do not see the email within a few minutes of me initiating this request, please check your spam/junk folder.

Applicant Email Address *

Please enter required data. Please enter a valid email address.

Confirm Applicant Email Address *

Please enter required data.

Please enter a valid email address.

Does not match previously provided email address.

Inform your client of the following

The Remote Signature email will include a Review and Sign Link. After clicking on the link, you will need to enter the access code you create.
I will need you to create an access code that you will easily remember.
The access code must be between 5-15 characters and can include both numbers and letters. It is case sensitive.
Please note the access code will expire after three failed attempts.

Access Code *

Please enter required data. Please enter a valid access code.

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

By clicking the Submit button below, you the agent/agent's representative agree the information was provided by the applicant, and you are submitting this change request on their behalf.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

The signature email was sent to {{appServiceModel.missingMedicareNumberObject.appEmail}} on {{appServiceModel.appStatusDateMax}} from adobesign.com. Please alert your client that they may need to check their spam/junk folder.

Within the body of the email, the client will find a link that will take him/her to a secure portal where he/she will be able to sign the form. They will have 24 hours to review and sign the form.

Upon the client authorizing or declining to sign the change request, a status email will be sent to the email address of the individual who initiated the change request.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Missing Replacement Notice

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

All fields marked with an * are required.

Please upload a copy of the applicant's Replacement Notice document*

The Replacement Notice must be completed in full. This includes the applicant's name, address, AARP membership number and signature, as well as the agent's signature.

Reminder: A copy of the signed Replacement Notice needs to be provided to the applicant.

Drag and drop your file here, or upload your documents

Only accepts PDF, JPG, JPEG, PNG format.
Upload up to 5 documents, max upload cannot exceed 9.5MB

Your documents

{{file.size}} MB

Remove

Your total document size maximum has exceeded 9.5MB.

You have uploaded too many documents. The maximum accepted is 5 documents.

You have attached an incorrect file format. Files must be a PDF, JPG, JPEG or PNG.

Your file did not upload successfully. Please try again.

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

By clicking the Submit button below, you the agent/agent's representative confirm the agent completed the Replacement Notice with the applicant and agree the information is accurate.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Missing Household Discount Information

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

This change only applies to UnitedHealthcare® Insurance Company of America plans.

Please complete the required fields with the applicant.

All fields marked with an * are required.

Applicant agrees to the following: *

I live in a household with at least one resident (no more than 3) that is currently an AARP member or will be on the plan effective date.

Please make a selection.

Name of Individual with the AARP Membership *

Please enter required data.

Please enter a valid first and last name.

Enter AARP Member Date of Birth*

Please enter a valid date

Inform your client of the following

You will receive a change request to sign via email; therefore, an email address will be required for you. By providing your email address, you are agreeing to apply your electronic signature as approval for this change.
While signing with Remote Signature, you will be using Adobe Sign, a trusted company that provides electronic signing for documents.
You will need to review and sign the change request within 24 hours of when I initiate this task. You are not required to sign and agree to the requested change. If the information is not accurate or you have additional questions, do not sign the form and please contact me.
If you do not see the email within a few minutes of me initiating this request, please check your spam/junk folder.

Applicant Email Address *

Please enter required data.

Please enter a valid email address.

Confirm Applicant Email Address *

Please enter required data.

Please enter a valid email address.

Does not match previously provided email address.

Inform your client of the following

The Remote Signature email will include a Review and Sign link. After clicking on the link, you will need to enter the access code you create.
I will need you to create an access code that you will easily remember.
The access code must be between 5-15 characters and can include both numbers and letters. It is case sensitive.
Please note the access code will expire after three failed attempts.

Access Code *

Please enter required data.

Please enter a valid access code.

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

By clicking the Submit button below, you the agent/agent's representative agree the information was provided by the applicant, and you are submitting this change request on their behalf.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

The signature email was sent to {{appServiceModel.missingHouseholdDiscountInfoObject.appEmail}} on {{appServiceModel.appStatusDateMax}} from adobesign.com. Please alert your client that they may need to check their spam/junk folder.

Within the body of the email, the client will find a link that will take him/her to a secure portal where he/she will be able to sign the form. They will have 24 hours to review and sign the form.

Upon the client authorizing or declining to sign the change request, a status email will be sent to the email address of the individual who initiated the change request.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Missing Part A or Part B Effective Date

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

Application #

Enter Medicare Part A Effective Date

Please enter a valid date The date must be the 1st of the month

Enter Medicare Part B Effective Date

Please enter a valid date The date must be the 1st of the month

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

Missing Tobacco Usage Indicator

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

Please complete the required fields with the applicant.

All fields marked with an * are required.

Select appropriate tobacco usage*

Yes - I have used tobacco in last 12 months

No - I have not used tobacco in last 12 months

Please make a selection.

Inform your client of the following

You will receive a change request to sign via email; therefore, an email address will be required for you. By providing your email address, you are agreeing to apply your electronic signature as approval for this change.
While signing with Remote Signature, you will be using Adobe Sign, a trusted company that provides electronic signing for documents.
You will need to review and sign the change request within 24 hours of when I initiate this task. You are not required to sign and agree to the requested change. If the information is not accurate or you have additional questions, do not sign the form and please contact me.
If you do not see the email within a few minutes of me initiating this request, please check your spam/junk folder.

Applicant Email Address *

Please enter required data.

Please enter a valid email address.

Confirm Applicant Email Address *

Please enter required data.

Please enter a valid email address.

Does not match previously provided email address.

Inform your client of the following

The Remote Signature email will include a Review and Sign Link. After clicking on the link, you will need to enter the access code you create.
I will need you to create an access code that you will easily remember.
The access code must be between 5-15 characters and can include both numbers and letters. It is case sensitive.
Please note the access code will expire after three failed attempts.

Access Code *

Please enter required data.

Please enter a valid access code.

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

By clicking the Submit button below, you the agent/agent's representative agree the information was provided by the applicant, and you are submitting this change request on their behalf.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

The signature email was sent to {{appServiceModel.missingTobaccoUsageObject.appEmail}} on {{appServiceModel.appStatusDateMax}} from adobesign.com. Please alert your client that they may need to check their spam/junk folder.

Within the body of the email, the client will find a link that will take him/her to a secure portal where he/she will be able to sign the form. They will have 24 hours to review and sign the form.

Upon the client authorizing or declining to sign the change request, a status email will be sent to the email address of the individual who initiated the change request.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Plan Selection Change (Pending Application)

Applicant Name: {{ appServiceModel.appDetailsObject.lastName }}, {{ appServiceModel.appDetailsObject.firstName }}

AARP Membership Number: {{ appServiceModel.appDetailsObject.aarpmemberNumber.replace("-", "")}}

If an AARP Membership Number is not displaying above, please provide the Application #

Application #

A pending application plan selection change request cannot be submitted via this method for applicants leaving or enrolling in an AARP® Medicare Supplement Plan insured by UnitedHealthcare® Insurance Company of America, applicants under the age of 65 or applicants enrolling in an AARP® Medicare Select Plan.

All fields marked with an * are required.

Please enter required data

Enter the Desired New Plan from the Menu *

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Missing Date of Birth

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

Application #

All fields marked with an * are required.

Please enter a valid date

Enter Date of Birth*

Please enter a valid date

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

Change Requested Plan Effective Date

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

All fields marked with an * are required.

Enter the Requested Plan Effective Date *

Please enter a valid date

The date must be the 1st of the month

The Plan Effective date must be after the signature date on the application, must be after the application receipt date, and must be no more then 12 weeks from the signature date.

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Provide Health Question Responses

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

All fields marked with an * are required.

Please upload a copy of the completed health questions for applicant's enrollment *

Complete Health Questions (i.e., if you cannot obtain the GI document and applicant wants the application to go through the Underwriting process). Ensure the Health and Tobacco questions are complete, the applicant re-signed and re-dated the Authorization and Verification of Application Information and Authorization for Verification of Information sections, and returned all pages of the application.

Drag and drop your file here, or upload your documents

Only accepts PDF, JPG, JPEG, PNG format.
Upload up to 5 documents, max upload cannot exceed 9.5MB

Your documents

{{file.size}} MB

Remove

Your total document size maximum has exceeded 9.5MB.

You have uploaded too many documents. The maximum accepted is 5 documents.

You have attached an incorrect file format. Files must be a PDF, JPG, JPEG or PNG.

Your file did not upload successfully. Please try again.

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

By clicking the Submit button below, you the agent/agent's representative confirm the agent completed the Health and Tobacco questions with the applicant and agree the information is accurate.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Missing Phone Number

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

Enter a Daytime Number

Please enter a valid phone number

Enter an Evening Number

Please enter a valid phone number

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

Missing Application Pages

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

Application #

All fields marked with an * are required.

Please upload a copy of the missing application page(s) *

Only submit the missing application pages being requested from the enrollment department.

Drag and drop your file here, or upload your documents

Only accepts PDF, JPG, JPEG, PNG format.
Upload up to 5 documents, max upload cannot exceed 9.5MB

Your documents

{{file.size}} MB

Remove

Your total document size maximum has exceeded 9.5MB.

You have uploaded too many documents. The maximum accepted is 5 documents.

You have attached an incorrect file format. Files must be a PDF, JPG, JPEG or PNG.

Your file did not upload successfully. Please try again.

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

By clicking the Submit button below, you the agent/agent's representative confirm the agent completed the missing application page(s) with the applicant and agree the information is accurate.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Withdraw Pending Application

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

Application #

All fields marked with an * are required.

The applicant wishes to withdraw their pending application *

Input is required

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

By clicking the Submit button, you the agent/agent's representative confirm the applicant has requested that their pending application be withdrawn, and you are submitting this request on their behalf.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Missing Gender

Applicant Name: {{appServiceModel.appDetailsObject.lastName}}, {{appServiceModel.appDetailsObject.firstName}}

AARP Membership Number: {{appServiceModel.appDetailsObject.aarpmemberNumber.replace('-','')}}

Please complete the required fields with the applicant.

All fields marked with an * are required.

Select gender*

Male

Female

Please make a selection

Inform your client of the following

You will receive a change request to sign via email; therefore, an email address will be required for you. By providing your email address, you are agreeing to apply your electronic signature as approval for this change.
While signing with Remote Signature, you will be using Adobe Sign, a trusted company that provides electronic signing for documents.
You will need to review and sign the change request within 24 hours of when I initiate this task. You are not required to sign and agree to the requested change. If the information is not accurate or you have additional questions, do not sign the form and please contact me.
If you do not see the email within a few minutes of me initiating this request, please check your spam/junk folder.

Applicant Email Address *

Please enter required data.

Please enter a valid email address.

Confirm Applicant Email Address *

Please enter required data.

Please enter a valid email address.

Does not match previously provided email address.

Inform your client of the following

The Remote Signature email will include a Review and Sign Link. After clicking on the link, you will need to enter the access code you create.
I will need you to create an access code that you will easily remember.
The access code must be between 5-15 characters and can include both numbers and letters. It is case sensitive.
Please note the access code will expire after three failed attempts.

Access Code *

Please enter required data.

Please enter a valid access code.

The information provided will be reviewed by the Enrollment Department related to the identified application. If the application is not pending, this request will not be considered.

By clicking the Submit button below, you the agent/agent's representative agree the information was provided by the applicant, and you are submitting this change request on their behalf.

Thank you for submitting your request!

Your change request for the above Applicant has been submitted.

The signature email was sent to {{appServiceModel.missingGenderObject.appEmail}} on {{appServiceModel.appStatusDateMax}} from adobesign.com. Please alert your client that they may need to check their spam/junk folder.

Within the body of the email, the client will find a link that will take him/her to a secure portal where he/she will be able to sign the form. They will have 24 hours to review and sign the form.

Upon the client authorizing or declining to sign the change request, a status email will be sent to the email address of the individual who initiated the change request.

We apologize, but we are unable to process your request at this time. Please resubmit the required information at a later time. Thank you for your patience.

Important Documents

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