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First Name*

Last Name*

Home Address (Apt/Suite/Unit number if applicable. Please note: P.O. Box/PMB cannot be accepted as a home address.)*

City*

State*

Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code*

Date of Birth*

Date of Birth

In order to see which plans you’re eligible for, you must submit your date of birth.

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Medicare Part B Effective Date*

Part B Effective Date

Your Medicare Part B Effective Date is when your Part B benefits become (or will become) active. It can be found on the front of your Medicare card.

Month January 1 February 1 March 1 April 1 May 1 June 1 July 1 August 1 September 1 October 1 November 1 December 1 Year 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966

What date do you want your plan to start?*

Plan Start Date

Please choose a date when you would like your Medicare supplement coverage to start. If you do not see the start date you are looking for please call 1-866-408-5545.

Select a Start Date

How would you like to receive your information?

Email Mail

Email*

Phone Number

This is a mobile number

By providing your address, phone number and/or email address, you are agreeing to receive information and be contacted/called by UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company of New York, Islandia, NY for NY residents).

By checking "I accept" below, I consent to receive telemarketing calls from or on behalf of UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company of New York for New York residents) about AARP Medicare Supplement Insurance Plans, including calls made with an autodialer or pre-recorded voice message, at the telephone number(s) above. I understand that my consent is not required as a condition of purchasing any goods or services from UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company of New York for New York residents).

I accept *

AARP Membership Number

AARP Membership Number

Enter your membership number as it appears on your AARP Membership card. If you can't find your AARP Membership card or need help locating your AARP Membership number, please call a customer service representative at 1-800-523-5800.

You DO NOT need to be an AARP member to request information. You DO need to be a member to enroll.

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Important Disclosures

AARP endorses the AARP Medicare Supplement Insurance Plans, insured by UnitedHealthcare Insurance Company. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers. AARP does not employ or endorse agents, brokers or producers.

You must be an AARP member to enroll in an AARP Medicare Supplement Plan.

Insured by UnitedHealthcare Insurance Company, Horsham, PA (UnitedHealthcare Insurance Company of New York, Islandia, NY for New York residents). Policy form No. GRP 79171 GPS-1 (G-36000-4).

In some states, plans may be available to persons under age 65 who are eligible for Medicare by reason of disability or End-Stage Renal Disease.

Not connected with or endorsed by the U.S. Government or the federal Medicare program.

This is a solicitation of insurance. A licensed insurance agent/producer may contact you.

THESE PLANS HAVE ELIGIBILITY REQUIREMENTS, EXCLUSIONS AND LIMITATIONS. FOR COSTS AND COMPLETE DETAILS (INCLUDING OUTLINES OF COVERAGE), CALL A LICENSED INSURANCE AGENT/PRODUCER AT THE TOLL-FREE NUMBER ABOVE.