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Application for The Medicare Supplement
Accredited Advisor Designation
Mail To: MSAA, PO Box 4459, Helena, MT 59604. Submit application fee.
(Print this Mail-In Application, complete it and send it with your check or money order to the address above.
For electronic application and to pay by credit card, go to On-Line Application)
NAME _________________________________
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AGENCY/COMPANY NAME
___________________________________________
DAY PHONE NUMBER ____-____-______
FAX NUMBER ____-____-______
E-MAIL ADDRESS (IF APPLICABLE—PRINT CAREFULLY)
___________________________________________
MAILING ADDRESS ____________________________
SHIPPING (STREET NEEDED)
___________________________________________
CITY, STATE, ZIP
_______________________, ____, ________
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Resident Insurance Producer’s License No.:
____________________
State: _________________
(Not needed if an Insurance Company Employee)
SSN: (For State CE Credit)
_______- ____- ________
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I herewith submit a $200.00 check or money order made out to: MSAA Designation. I understand that if I earn, and am awarded this designation, the designation does not allow me to associate myself in any way with Medicare, or any other government entity, nor am I allowed to hold myself out as a representative of such. I understand that, should I not satisfactorily complete both examinations within three months of the date of receipt of course materials, I will be allowed an additional thirty days in which to satisfactorily complete both examinations.
If I do not satisfactorily complete both examinations there will be a $25.00 refund.
SIGNATURE ____________________________ DATE _______________
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(For electronic application and to pay by credit card, go to On-Line Application.)
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