Enrollment Form
OPEN ENROLLMENT OCTOBER 15 - DECEMBER 31, 2022
All IBOs age 65 or older enrolled in Medicare Part A & B: Open enrollment for group retiree health and Part D Prescription Drug coverage is October 15 – December 31, 2022. Coverage is guaranteed acceptance regardless of pre-existing health conditions. If you enroll by December 31, 2022 your coverage will be effective January 1, 2023. If you enroll after December 31, you may qualify for coverage by answering a few health questions.
Listed below are easy to follow step-by-step instructions to complete the Retiree Health plan enrollment process:
- Read the details of the Retiree Health Plan Benefit Information.
- Click on the link at the bottom of this page and print the enrollment form.
- Complete the form in ink:
- Name and complete address
- Daytime Phone Number
- Social Security Number
- Date of Birth and Gender
- Your Medicare Card data. Fill in your Medicare Claim Number and the effective date of your Medicare Part A and Part B. Your enrollment will not be processed without your current Medicare data.
- Your IBO Number. Pin Level is optional.
- Select the plan in which you wish to enroll.
- Sign and date the form. If your spouse is also enrolling, he/she must complete, sign, and date the Spouse section of the form.
- Do not submit your premium payment now; you will receive payment options with your policy.
Your premium payments options will be: ACH (authorization for bank account deduction) or direct bill to your home
Mail your completed enrollment form to:
Varipro
IBOBA Insurance Program
5300 Patterson Ave, Suite 150
Grand Rapids, MI 49512
Download a copy of our United American Retiree Health Plan Enrollment Form.
For more information, call the Group Medicare Supplement Call Center at 1-800-732-3412.