Enroll in an Empire Medicare Supplement Plan
PW_B141836
If you need to review the plan documents before applying, please see below:
Plan Information for New York and Mid-Hudson Regions:
Use the following materials if you live in one of these counties.
Bronx, Kings, Nassau, New York (Manhattan), Queens, Richmond, Rockland, Suffolk, Westchester, Dutchess, Orange, Putnam, Sullivan and Ulster
Sales Brochure
Outline of Coverage
Rates
Application
Premium Payment Form
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Plan Information for Albany Region:
Use the following materials if you live in one of these counties.
Albany, Clinton, Columbia, Delaware, Essex, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington
Sales Brochure
Outline of Coverage
Rates
Application
Premium Payment Form
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Get an Empire Medicare Supplement quote! Enter your ZIP Code to review the rates for Empire’s Medicare Supplement Plans in your area.
Choose your method of enrollment:
You can apply online or mail your enrollment application.
Step 1. Select the appropriate enrollment form to download and print, or select the link for the online enrollment application. Fill out the application completely.
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New York and Mid-Hudson Regions:
Use the following materials if you live in one of these counties:
Bronx, Kings, Nassau, New York (Manhattan), Queens, Richmond, Rockland, Suffolk, Westchester, Dutchess, Orange, Putnam, Sullivan and Ulster
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To mail your enrollment application, download the print the application form:
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To apply online, access our easy-to-use online enrollment application and submit it to our secure mail box for processing:
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Albany Region:
Use the following materials if you live in one of these counties:
Albany, Clinton, Columbia, Delaware, Essex, Fulton, Greene, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington
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To mail your enrollment application, download the print the application form:
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To apply online, access our easy-to-use online enrollment application and submit it to our secure mail box for processing:
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Use these helpful tips for completing your application:
Complete the application in blue or black ink. Make sure your information is accurate and easy to read so we can process your application smoothly. Complete the Premium Payment Form if applicable. (See below for details.)
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Check your Medicare card to be sure that your name reads exactly the same on the application as it does on your Medicare card.
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Determine if you want to sign up for Automatic Bank Draft.
We can automatically withdraw funds from your bank account to pay your plan premium. No more check writing. No more postage costs. Plus, you won’t have to worry about a lapse in coverage if you were to forget to pay your bill. You can begin using Automatic Bank Draft with your first month’s premium…have funds transferred from either checking or savings, even change banks. You will receive a discount for choosing this billing method. See the Outline of Coverage for details.
If you want to sign up for Automatic Bank Draft, you need to:
 | Complete the Premium Payment Form. |
| See the Rate Sheet for your chosen plan’s monthly premium amount. |
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Tell us the best number to reach you. One of our representatives may be calling you to go over the plan information and to make sure that the information on your application is accurate.
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Carefully review your application, sign it, date it and mail it to the address listed in Step 2.
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Step 2. Mail your completed application to the following address:
Enrollment Processing Center
P.O. Box 5007
Middletown, NY 10940-9007
When you’re ready to talk or just want more information, we’re only a phone call away.
| Contact your broker, or call a benefits expert at 1-800-809-7328 (TTY/TDD: 1-800-241-6894) 8 a.m.–8 p.m., seven days a week. They’re here to help you understand all the possibilities and benefits available to you once you become eligible for Medicare. |
| You also can call 1-800-MEDICARE (1-800-633-4227). Customer service representatives are available 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. |
The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent or insurance company.
This policy meets the minimum standards for MEDICARE SUPPLEMENT INSURANCE as defined by the New York State Insurance Department. The expected benefit ratio for this policy is 80%. This ratio is the portion of future premiums which the company expects to return as benefits, when averaged over all people with this policy. Products offered are not connected with or endorsed by any division or agency of the state of New York, the United States government, or the Federal Medicare program.
Policy form numbers: WPPLANAM(09)-NY, WPPLANBM(09)-NY, WPPLANFM(09)-NY, WPPLANHiFM(09)-NY, WPPLANGM(09)-NY, WPPLANNM(09)-NY
A CONSUMER’S GUIDE TO HEALTH INSURANCE FOR PEOPLE ELIGIBLE FOR MEDICARE MAY BE OBTAINED FROM YOUR LOCAL SOCIAL SECURITY OFFICE OR FROM THIS INSURER.
WPADVWS001M(10)06-NY
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