Fillable APPLICATION FOR MEDICARE SUPPLEMENT INSURANCE * UNITED AMERICAN INSURANCE COMPANY 3700 S

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APPLICATION FOR MEDICARE SUPPLEMENT INSURANCE * UNITED AMERICAN INSURANCE COMPANY 3700 S. STONEBRIDGE DRIVE* MCKINNEY, TEXAS 75070* A LEGAL RESERVE STOCK COMPANY PART I: APPLICANT INFORMATION Plan Code (Refer to Rate Card) Effective Date Requested (mm-dd-yyyy) Mode of Premium Payment Annual Semi-Annual Method of Payment Send Premium Notices Automatic Payment Plan Draft Date Day (01-28) of the Month to Draft Bank...
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