Enrollment

It is important that you understand the details of the plan you are interested in purchasing. You can use this Web site to read about the product(s) you are considering.

When you have determined which plan(s) you wish to enroll in, or if you require additional information, just let us know. We'll send you information on the product(s) of your choice. Simply complete this form telling us which product(s) you are interested in. (Note: Fields marked with an * are optional entries)

Enrollment Form
Send me information on the plan(s) I have checked below (A sales representative may call with information)
First Name
Middle Initial*
Last Name
Date of Birth (mm/dd/yyyy)
Street Address
City
State
Zip Code
County
E-mail Address*
Telephone Number with Area Code*
Please send me information on your: Medicare Supplement Plans Long Term Care Plans SecurityChoice Private Fee For Service Plan FinalExpense Whole Life Insurance Plans
I am Currently: (select one) A UniCare Medicare Supplement Plan Member A Member of Another UniCare Plan Not a Member of any UniCare Plan
Other Information you would like to provide to us

If you wish, you can also request an enrollment package by calling one of our new enrollment representatives. Just call 1-800-459-1732 ext. 720 anytime between the hours of 6:30am and 5:30pm (PT) 8:30am to 7:30pm (CT). Monday through Friday (excluding holidays)