Click here for a tutorial on the on-line application process.
Acrobat Reader is Required
You must have the Adobe Acrobat Reader Version 7 or higher installed on your computer and configured to be used with your web browser. If you do not currently have Adobe Acrobat Reader, it can be downloaded at no charge by clicking on the following link: Get Adobe Acrobat Reader.
This web application uses Adobe Forms that you fill in on-line. If you are not familiar with Adobe Forms click on Help for more information.
» Dental, Vision and Hearing Application
Welcome to the secure On-Line Application website for Medico™ Insurance Company. You have been directed to this web site by our agent:
ERIN E ZIEGELBAUER
If this is not correct, please contact your agent or Medico Insurance Company. Our contact information can be found by clicking on the "Contact Us" link shown above.
You must be able to print or store an electronic record of the information related to your application for a Dental, Vision and Hearing Insurance Policy. You will be provided the opportunity to print and/or save this record at the end of the application process. You may obtain a paper copy of all notices at any time, even after you consent to receive notices electronically. Please contact us and we will mail any requested notices to you.
Select your state of residence from the drop-down list shown here. To review the details of this policy, click on the link "Show Brochure."
Click on the following link if you cannot store this information electronically and you choose to complete the application on-line and print it. You may then sign the application and submit it by mail or fax it to us. The agent may also upload the applications(s) to the MIC website. If you choose to apply electronically, please disregard this link and click on the "Continue" button below to submit the application electronically.
You have the right to withdraw your consent to this electronic transaction at any time. Click on a "Stop" button or close this browser session. If you choose to withdraw your consent, the information you have entered will be lost and your application will not be submitted to Medico Insurance Company.
I understand that by clicking on the "Continue" button, I am agreeing to complete an application for a Dental, Vision and Hearing Insurance Policy with Medico Insurance Company through an electronic application process and that I have the ability to access electronic records. I am also agreeing to accept an electronic record of all documents that are required to be furnished to me by Medico Insurance Company as part of the application process.
I understand that if I do not wish to apply for a Dental, Vision and Hearing Insurance Policy with Medico Insurance Company, or if I do not have the ability to access electronic records, I should click on the "Stop" button.
