Enrollment Form
Medicare Part D Prescription Drug Coverage Only
You and your spouse are eligible to enroll in our SilverScript® Insurance Company plan if you are an active IBO and a member of the Independent Business Owners Benefits Association (IBOBA), or spouse, a U.S. citizen living in the United States and hold a social security number. You must also be enrolled in both Medicare Part A and Medicare Part B. Prescription Drug Coverage may be purchased separately during open enrollment periods or at the same time you are eligible to purchase a Medicare supplement policy.
Listed below are easy to follow step-by-step instructions to complete the Medicare Part D Prescription Drug Coverage (only) enrollment process:
- Click on the link at the bottom of this page to print the enrollment form.
- Complete the enrollment form 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 box “Medicare D Prescription”.
- 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 Enrollment Form.
For more information, call the Group Medicare Supplement Call Center at 1-800-732-3412.