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SCORE-Bench

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1. ENTER YOUR HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER (include coverage through spouse or other person)
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1-800-601-3372
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AARP/United Healthcare 202 Hall’s Mill Rd. Stanton, NJ 08889
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2. NAME OF POLICY HOLDER
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Robert James Eckersley
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3. POLICY NUMBER
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B10586
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4. GROUP CODE
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001
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5. ARE YOU ELIGIBLE FOR MEDICAID?
(Federal health insurance for low income adults)
[] YES
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[x]
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NO
6A. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?
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[x]
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YES [] NO
6B. EFFECTIVE DATE
(MM/DD/YYYY)
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01/01/2025
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6C. MEDICARE NUMBER
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1EG4-TE5-MK72
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SECTION IV - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)
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1. SPOUSE'S NAME (Last, First, Middle Name)
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Eckersley Janet Louse
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1A. SPOUSE'S SOCIAL SECURITY NUMBER
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658-06-7388
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1B. SPOUSE'S DATE OF BIRTH (MM/DD/YYYY)
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01/18/60
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1C. SPOUSE'S SEX
[] MALE
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[x]
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FEMALE
1D. DATE OF MARRIAGE (MM/DD/YYYY)
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05/30/80
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1E. SPOUSE’S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP if different from Veteran’s)
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2. CHILD'S NAME (Last, First, Middle Name)
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2A. CHILD'S DATE OF BIRTH
(MM/DD/YYYY)
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2B. CHILD'S SOCIAL SECURITY
NO. (999-99-9999)
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2C. DATE CHILD BECAME YOUR DEPENDENT (MM/DD/YYYY)
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2D. CHILD'S RELATIONSHIP TO YOU (Check one)
[] SON [] DAUGHTER [] STEPSON [] STEPDAUGHTER
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