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Consumer Assistance
Home and Auto Rate Comparisons
Insurance Basics
GetReady
Information for Seniors
External Review Process
Public Rate & Form Filings
Workers' Compensation
Health Care Reform Resources
Licensing and Education
Anti-Fraud Unit
Regulated Entities
Bail Bonds
Financial
Regulated Industry Services
Surplus Lines
Premium Tax Forms
Certified Reinsurers
Insurers
Rate and Form Filing
Real Estate Appraiser Board (REAB)
Insurance Business Transfers
Public Information
About OID
News
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Legal
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State of Oklahoma Insurance Verification System
Home
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23312332
SHIP Shoppers Guide 2017-2018 Data Input Form
Please take a moment to fill out the form below. Hit "submit" when you are finished in order to send the form back to us. This information will be compiled into a publication to be made available for use in the Senior Health Insurance Counseling Program. Thank you for your cooperation. If you have any questions please feel free to contact our office at (405) 522-4683 or in-state at 800-763-2828.
*
Indicates Required Field
*
Contact Person:
*
Company Name:
*
Contact Address:
*
City:
*
State:
*
Zip Code:
(no dashes e.g. 555554444)
*
Contact Phone:
(no dashes e.g. 5554443333)
*
Phone Number to be Printed:
(no dashes e.g. 5554443333)
*
Address to Be Printed:
*
E-mail Address:
Please mark the following that apply to your company:
INDIVIDUAL Medicare Supplemental Plans currently offered by Company:
A
B
C
D
F
G
K
L
M
N
Medicare Supplement Plans available to Disabled Medicare beneficiaries:
A
B
C
D
F
G
K
L
M
N
ALL PLANS AVAILABLE FOR SALE MUST BE GUARANTEED DURING SIX MONTH OPEN ENROLLMENT AS REQUIRED BY OKLAHOMA REGULATION 365:10-5-129
*
Do you market a Medicare Supp Plan to DISABLED Medicare beneficiaries, OUTSIDE of open enrollment?
Yes
No
Medicare SELECT Plans currently offered by Company:
A
B
C
D
F
G
K
L
M
N
Does your company offer a HIGH DEDUCTIBLE Plan?
F
Please include an ANNUAL Rate Schedule for each plan offered to Individual Beneficiaries age 65 female non-smoker.
A
B
C
D
F
F*
G
K
L
M
N
Please include an ANNUAL Rate Schedule for each plan offered to Individual Beneficiaries under 65.
A
B
C
D
F
F*
G
K
L
M
N
Please include an ANNUAL Rate Schedule for each Medicare Supplement SELECT plan offered to Individual Beneficiaries age 65 female non-smoker.
A
B
C
D
F
F*
G
K
L
M
N
*
Method of Premium Rate
--Please Choose--
Attained Age
Issued Age
No Age Rating
*
Pre-existing Condition Limitation
--Please Choose--
6 months
3 months
Waived during open enrollment period
Remarks:
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