• First name
• Middle initial (optional)
• Last name
• Suffix (Jr., Sr., III) (optional)
• Date of birth - Please make sure you have the right date. If the applicant is not at least age 64½ years, the system will prompt you to call the customer service line for assistance. All applicants must be at least 64½ years old to apply.
• Gender
• Home telephone number (optional)
• Social Security Number - please enter without dashes (-) or slashes (/).
• Medicare number (optional)
• Coverage start date.

When you see a single asterisk (*) next to a field, that means we require that information. The system won't let you continue on to other pages if those fields are incomplete.