Forms & Resources

Medicare Supplements are insured by Members Health Insurance Company, Columbia, TN. Not connected with or endorsed by the U.S. or state government. This is a solicitation of insurance. A representative of Members Health Insurance Company may contact you. You must be a member of Indiana Farm Bureau, Inc. to enroll in Indiana Farm Bureau Medicare Supplement Plans.

MH-ING-CERTA-FL20-131; MH-ING-CERTD-FL20-093; MH-ING-CERTG-FL20-095; MH-ING-CERTN-FL20-097

Forms & Resources

Forms Used with a New Application

Medical Request Form

(age 0-2 months)

Medical Request Form

(age 3-25 months)

Medical Request Form

(age 40 and older)

General Medical Request Form

Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage

Claims Forms

Under 65 Health

Coverage Claim Form

Medicare Supplement Subscriber

Health Care Claim Form

Under 65 Prescription Drug Claim Form

At-Home COVID-19 Test Kit Reimbursement Form

Forms for Underwriting Reconsideration

Request for Reconsideration of

Benefit Exclusion Rider

Request for Reconsideration of Rate

Request for Reconsideration of

Declined Coverage

Request for Reconsideration of

Tobacco Rate

Coverage Information

Advanced Choice Traditional Plan Schedule of Benefits

Classic Choice Traditional Plan Schedule of Benefits

Major Medical Plan

Schedule of Benefits

High Deductible Plan

Schedule of Benefits

Dental/Vision Plan

Schedule of Benefits

Medicare Supplements

Outline of Coverage

To download the coverage comparison for our Traditional Health Plans, click here.

Other Useful Forms

Grievance Form - Under 65 Plans

Grievance Procedures - Under 65 Plans

Bank Draft Authorization Form

(Under 65)

Bank Draft Authorization Form

(Over 65)

Personal Representative Designation

Medicare Supplement Change Form

U65/Traditional Plans

Change/Transfer Form

Cancellation Form for Members

Under 65

Cancellation Form for Members

Over 65

Indiana Other Insurance Form

Prescription Mail Order Form

Prescription Mail Order Instructions

How to Pay Your Initial Invoice

For more information, call1-888-964-0854

Quick Links

Terms & Policy

Get in touch

For more information, call
1-888-964-0854