Pooled Trust Application

The joinder process for the pooled trust includes an evaluation of your situation, and confirmation that by joining the trust you will qualify to keep your existing benefits. This eForm is the start of the process.

PRIVACY STATEMENT – Senior Medi-Benefits NEVER shares any private, personal information with outside parties. All correspondence and submissions are 100% confidential.

TO BEGIN JOINDER PROCESS ONLINE fill out form below and submit.

Your Age:
County of Residence:
Type of Current Benefit:
Type of Lump Sum:
Distribution Amount:
Date Distribution Expected to occur:

WE NEED THE FOLLOWING INFORMATION so we can contact you, email trust documentation to you & set up a time for a formal Joinder interview.

* Email Address:
Phone Number:
* Your Name: