Offered by Capital Advantage Insurance Company® 
Medically Underwritten | 2010 Standardized Medicare Supplement Plans Enrollment Application

BlueReliance Medicare Supplement

Enrollment Application: Overview

What are the advantages of a Medicare Supplement insurance policy?

  • Helps pay some of the expenses not covered by Medicare
  • Your out-of-pocket healthcare costs are reduced
  • You choose your own doctors, hospitals and other healthcare providers
  • Benefits designed to address Medicare's deductibles and co-payments

Coverage is provided on an individual basis. Please complete ONE application per person.

To avoid delays in processing, be sure to complete every question in the application. You will need to have available the following:

  • Applicant's existing insurance company name(s) and policy effective date(s)
  • Applicant's Medicare card (Red, White, & Blue health insurance card)

Applications received by Capital Advantage Insurance Company are normally processed within 10 business days. You will receive notification of approval/denial after processing is completed.

Approved applicants will receive:

  • Member ID Card
  • Post-enrollment packet that includes your insurance policy, information regarding claims processing and tracking, premium payment options, customer service contacts, etc.

* If you are applying as a Power of Attorney (POA), you will need to Print A Paper Application for completion.

Required fields are noted with an asterisk *.

BlueReliance Medically Underwritten 2010 Standardized Medicare Supplement plans are issued by Capital Advantage Insurance Company®, a subsidiary of Capital Blue Cross. Independent licensees of the Blue Cross Blue Shield Association. Communications issued by Capital Blue Cross in its capacity as administrator of programs and provider relations for all companies. You must be enrolled in Medicare Parts A and B. Please refer to the BlueReliance Medicare Supplement Outline of Coverage for actual premiums and costs.