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FORMS

Brochures, Enrollment Information & Forms

HCTC Forms & Brochures

HCTC  - (HEALTH COVERAGE TAX CREDIT)

completed sample forms available at bottom of this page for 13441-A form

SUMMARY PLAN DESCRIPTIONS FOR HCTC PLANS

Medicare Forms & Brochures

MEDICARE

The Enrollment form is for all States, with the exception of Florida.

PLEASE CONTACT BENISTAR CALL CENTER IF YOU ARE ENRO:LLING AND LIVE IN FLORIDA.

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

SUMMARY PLAN DESCRIPTIONS FOR HARTFORD MEDICARE PLANS

Brochures, Enrollment Information & Forms

HCTC Forms & Brochures

HCTC  - (HEALTH COVERAGE TAX CREDIT)

completed sample forms available at bottom of this page for 13441-A form

SUMMARY PLAN DESCRIPTIONS FOR HCTC PLANS

Medicare Forms & Brochures

MEDICARE

The Enrollment form is for all States, with the exception of Florida.

PLEASE CONTACT BENISTAR CALL CENTER IF YOU ARE ENRO:LLING AND LIVE IN FLORIDA.

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

SUMMARY PLAN DESCRIPTIONS FOR HARTFORD MEDICARE PLANS

Brochures, Enrollment Information & Forms

HCTC Forms & Brochures

HCTC  - (HEALTH COVERAGE TAX CREDIT)

completed sample forms available at bottom of this page for 13441-A form

SUMMARY PLAN DESCRIPTIONS FOR HCTC PLANS

Medicare Forms & Brochures

MEDICARE

The Enrollment form is for all States, with the exception of Florida.

PLEASE CONTACT BENISTAR CALL CENTER IF YOU ARE ENRO:LLING AND LIVE IN FLORIDA.

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

SUMMARY PLAN DESCRIPTIONS FOR HARTFORD MEDICARE PLANS

SAMPLE 13441A Enrollment Forms

(RETIREE ENROLLING)
(SINGLE PERSON ENROLLING)
(FAMILY ENROLLING)
(QUALIFIED FAMILY MEMBER ENROLLING)

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