Celebrating 65 Social Security

Register to view our online presentation on Simplifying Medicare

*Required fields

Please enter the following information.

VIP# (Find this number on any piece of advertising about Harvard Pilgrims Medicare options that you received in the mail.)

E.g. for VIP-BBB0000000000 enter only BBB0000000000

First Name*

Last Name*

Address*

City*

State*

Zip Code*

E-Mail

Home Phone

Mobile

Work Phone

Date of Birth (mm/dd/yyyy)

Email address will only be used for post-event survey. You will receive communications from noreply@qemailserver.com

Are you currently a Harvard Pilgrim member?

Yes*

No*

How do you receive your current health insurance?

Through my employer

Through my spouse's employer

Individual Insurance

Are you enrolled in Medicare?

Yes*

No*

If No, when will you be enrolling into Medicare? (mm/dd/yyyy)*

I am interested in Harvard Pilgrim's Medicare options.

Yes*

No*

By clicking "View the Simplifying Medicare Presentation" you are agreeing to receive a phone call or mail from Harvard Pilgrim Health Care to follow up on your interest .