Get a Free Quote | TEAMStar Retiree Health Plan

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Applicant rates not found

Even though rates are shown, you will not be eligible to apply for {{ratequote[0].DaysLeftIneligible}} days.

Monthly Monthly bank draft Quarterly Semi-annually Annually
	{{selectQuote.PlanDesc}}	{{selectQuote.PlanRate \| currency: "$":2}}

Spouse rates not found

Even though rates are shown, you will not be eligible to apply for {{ratequote[1].DaysLeftIneligible}} days.

Monthly Monthly bank draft Quarterly Semi-annually Annually
	{{selectQuote.PlanDesc}}	{{selectQuote.PlanRate \| currency: "$":2}}

SAVE $2 PER PAYMENT BY SELECTING MONTHLY BANK DRAFT

Applicant must have applicable rates in order to proceed.
Please verify the applicant birthdate.

Depending on the plan you select, coverages pay various Medicare deductibles, coinsurances and medical/doctor expenses not covered by Medicare. See the Summary of Benefits for more details.

*$1 pays for the first month’s premium for first time enrollees only and is not available in all states. Rates after the first month are shown above.

Primary Applicant Information Name: {{applicant.Firstname + " " + applicant.LastName}} Address: {{applicant.Addr1 + " " + applicant.Addr2}} City/State/Zip: {{applicant.City + ", " + applicant.StateCode + " " + applicant.Zipcode}} Date of Birth: {{applicant.DOB \| date:'MM/dd/yyyy'}}	Selected Rate Quote Plan Selection: {{applicant.PlanDesc}} Rate Selection: {{applicant.Premium \| currency: "$":2}} Payment Frequency: {{applicant.PayMethodDisplay}}

Medicare # *

Retired IBT Local # *

Policy Effective Date *

Health Questions

TO THE BEST OF YOUR KNOWLEDGE:

Questions 7-12 not required for applicants who are within 6 months of their enrollment in Medicare Part B. IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS "YES", THE INDIVIDUAL WHO GIVES THE "YES" ANSWER IS NOT ELIGIBLE FOR COVERAGE. {{question.QuestionOrder}}. {{question.QuestionText}} * Yes No Yes No {{questionpart.QuestionPartText}} {{questionpart.QuestionPartText}} {{questionpart.QuestionPartText}} {{questionpart.QuestionPartText}} Yes No {{questionpart.QuestionPartText}}

Spouse Information Name: {{spouse.FirstName + " " + spouse.LastName}} Date of Birth: {{spouse.DOB \| date:'MM/dd/yyyy'}}	Selected Rate Quote Plan Selection: {{spouse.PlanDesc}} Rate Selection: {{spouse.Premium \| currency: "$":2}} Payment Frequency: {{spouse.PayMethodDisplay}}

Medicare # *

Policy Effective Date *

Health Questions

TO THE BEST OF YOUR KNOWLEDGE:

Questions 7-12 not required for applicants who are within 6 months of their enrollment in Medicare Part B. IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS "YES", THE INDIVIDUAL WHO GIVES THE "YES" ANSWER IS NOT ELIGIBLE FOR COVERAGE. {{question.QuestionOrder}}. {{question.QuestionText}} * Yes No Yes No {{questionpart.QuestionPartText}} {{questionpart.QuestionPartText}} {{questionpart.QuestionPartText}} {{questionpart.QuestionPartText}} Yes No {{questionpart.QuestionPartText}}

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Bank Draft Billed by Mail

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Last Name *

Account Number *

Reenter Account Number *

Routing Number *

Draft Day *

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Account Numbers do not match

Applicant Signature * Signed At *

Spouse Signature * Signed At *

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