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Medicare Supplement Pre-Application

The North Carolina Senior Citizens Association (NCSCA) endorses and recommends Mutual of Omaha Medicare Supplement Plans. However, if you prefer a different company or plan,  we can help. If you have any questions or need assistant in completing the online application, please call 1-800-290-7535. 

                North Carolina's #1 Medicare Choice For More Than 40 years.

      Click the Icon Below To Compare Premium Rates 

Plan G Premium Rate Comparison Chart

Yes - I understand I am under no obligation.

Our online application is secure and easy to use.
Call for assistance or to apply over the phone at 1-800-290-7535.

Section 1: Medicare Supplement Enrollment Form

To help us provide you with a FREE Medicare Supplement Quote with the lowest premium and highest financial rating, please answers the questions below.

We will send the Medicare Supplement Application to your e-mail or mailing address:*

A. Select the way you want to receive the Official Medicare Supplement Enrollment Application:*
Email Application
Mail Application

Section 2: Applicant A Information

Applicant A:

First* Middle Initial:


Does Applicant A prefer Mutual of Omaha Plan G? It has the lowest Premium Rate and the highest financial rating in North Carolina? Yes     No

If NO, what company do you prefer?

Select the Plan that you prefer* Plan A     Plan F     Plan G     Plan N     Other Plan

If Other Plan, what plan do you prefer?

Requested Effective Start Date: /

Residence Address*

Mailing Address (if different from residence address)

City* County State* Zip*


Home Phone Cell Phone

Current Age* Date of Birth* // Gender:* Male Female



Has Applicant A used tobacco in the last 12 months?

Does Applicant A currently have a Medicare Supplement Policy? Yes No

If yes, Name of Insurance Company

Does Applicant A currently have coverage under a group, individual, union, or COBRA policy? Yes No

IF YES, Name of Insurance Company

Type of Policy: Group Individual Union COBRA

Applicant A: Questions or Comments (if any)
Section 3: Applicant B - Premium Discount Information
You might be able to SAVE 12% with a NC Senior Citizens Household Premium Discount.

Do you either:

1. Reside with your spouse or domestic partner? Yes No

2. Reside with an adult age 60 or older and have resided with that person for at least one year? Yes No

If you answered YES to either question above you quality for the 12% household premium discount! Please complete following information for Applicant B.

Applicant B Premium Discount Information:

First Last Zip* (Zip Code Must Match Applicant A)

Date of Birth* //

Gender:* Has Applicant B used tobacco in the last 12 months?*



Does Applicant B want to Apply for a Medicare Supplement Policy? No     Yes

Applicant B: Comments or Questions? (if any)
Section 4: Medicare Claim Number Information:

Please reference your Medicare Card to complete this section. If you have not yet received your Medicare Card, indicate the date you plan to enroll in Medicare Part A and Part B.


Applicant A:

Medicare Claim Number:

Medicare Part A Effective Date: -01-

Medicare Part B Effective Date: -01-

Section 5: Premium Payment Options

Select the premium payment option.

Do you prefer automatic bank account withdrawal each month? Yes No

If Yes, do you prefer payments withdrawn on the:
1st day of the month     OR     15th day of the month

If No, do you prefer to mail your premium payment:
Every Month ($2 extra charge) Every 3 Months Every 6 Months Every 12 Months

Section 6: Open Enrollment, Guaranteed Issue Eligibility and Switching Medicare Supplement Plans

If applying during an Open Enrollment or Guaranteed Issue Period, the Applicant is NOT Required To Answer Health Information.

1. "Open Enrollment"?
Applicant is at least 64 1/2 years of age and within 6 months before or after Medicare Part B effective date. Open Enrollment Example: If you are turning 65 and will enroll in Medicare Part B in the next six months or if you are over 65 and enrolled in Medicare Part B within the last six months, you are NOT required to answer health questions.

2. "Guaranteed Issue Period"?
Applicant is enrolled in Original Medicare, has an employer group health plan, COBRA or union coverage that pays after Medicare, and that coverage is ending. Guaranteed Issue Example: If you are coming off your employer group coverage or COBRA health insurance plan; your Medicare Advantage Plan stops providing coverage in your area; you decide to switch back to Original Medicare within the first year of joining a Medicare Advantage Plan when you first became eligible; you are NOT required to answer health questions for Plan F, but with most companies will required you to answer health questions to purchase Plan G.

3. "Switching Medicare Supplement Plans"?
Applicant has the right to switch their current Medicare Supplement plan anytime during the year. However, in most cases, you will be required to answer health questions with most companies to qualify.

Are you applying during your "Open Enrollment"?
Yes No Unsure
Are you applying during your "Guaranteed Issue Period"?
Yes No Unsure
Are you applying to switch Medicare Supplement Plans?
Yes No

Click Here for Open Enrollment and Guaranteed Issue Worksheet

*Required Information

NC2013WP, 5/1/15

Our Medicare Specialist Will NOT Call You Unless Requested