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This form is to be used by self-employed
MAR members
Please complete the following information online or print, complete, and fax
(248-593-2065) to Group Associates for personalized proposals and enrollment
instructions. If you have any questions, please call (800) 342-8908 x2810. Thank
you for your interest.
Click here for a printer friendly version to fax
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| Please indicate your quote request |
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| Your Personal Information |
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Last Name
First Name
MI
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Date of Birth
Gender (Male or Female)
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Home Address
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City, State, Zip Code
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Home Phone
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If you are over the age of 65, are you enrolled for Medicare? (Part A
& B)
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| Your Family Member's Information |
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Spouse's Name
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Spouse's
Date of Birth
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your Spouse is over the age of 65, is your Spouse enrolled for Medicare? (Part
A & B)
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Number
of dependent children born after 12/31/1988 |
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Number
of dependent children born after 01/01/1983, but before 12/31/1988
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| Your Professional Information |
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Year
started as a REALTOR
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Work Address |
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City, State, Zip Code |
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Work Phone
Fax*
Mobile*
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| Email
Address* |
| Information Blue Cross underwriters ask to determine
your eligibility to participate in the MAR Blue Cross program
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Are you the primary income earner in your household, if married? |
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Does your spouse qualify for medical insurance from her/his employment? |
| * indicates optional information |
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