Last 4 digits of SSN:
Enter the last 4 digits of your own SSN
Date Of Birth:
Enter your own birthdate in MM/DD/YYYY format.
The name information you enter below must appear exactly as it is on your insurance card. Examples for an insurance card bearing the name John Q. Doe Jr. appear by the appropriate boxes below.
Enter your Group Number as it appears on your insurance card
Example: Doe Jr.
Enter the last name as it appears on your insurance card, including any Jr/Sr specifications (if on card).