Application Form

Yes! I want to become a Just for Seniors member

To apply, fill out and submit this online form or view (PDF), print, and mail the form.

I understand that the membership program is not an HMO or a Medicare supplemental insurance product. Medicare is not a requirement for this free program. Adequate hospital coverage is my responsibility.

You may also view (PDF) and print this form to apply by mail.

Questions? Email [email protected].