Use the online e-Enrollment Application

Apply for coverage from Asuris Northwest
Plan choices (PDF) | Plan Rates | Medicare Supplement Enrollment Application | Medicare and You 2006

Application Process and Forms

To apply for any of the Asuris Northwest Washington Medicare Supplement plans, please complete the following steps:

How to Enroll

You may be enrolled in only one Medicare Supplement policy at a time.

1. Please review your plan choices and rates (PDF)
   
   
2. Please be sure to review Medicare and You 2006.  The Federal Government requires that this brochure is available to you and that we offer it to you when Medicare is discussed.
   
   
3. If you are replacing your current Medicare supplemental coverage, fill out the replacement form (PDF) in addition to the other documents noted below
   
   
4. Fill out the Washington Medicare Supplement Enrollment Application (PDF)



5. Include a check or money order for 2 months payment. If you prefer to use Automatic Bank Charge (ABC), fill out Section G
   
   
6. Include a copy of the Certificate of Coverage from a prior insurer, if it applies.
   
   
7. Sign your application
   
   
8. Submitting Your Enrollment Materials
   
   • Coverage starts on the first of the month after the application postmark date, unless you request a later date (no more than 90 days after the postmark date).
     
     
9. Send all Enrollment Materials to:
   CDA Insurance
   P.O. Box 26540
   Eugene, OR 97402