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Ssa insurance form. We are writing to you because we need to know more about your work. I apply for a period of disability and or all insurance benefits for which i am eligible under title ii and part a of title xviii of the social security act as presently amended. Print name of wage earner or self employed person. Page 1 of 8.
The social security administration is authorized to collect the information requested on this form under sections 202 205 and 223 of the social security act. Form ssa 821 bk 01 2019 uf discontinue prior editions. Page 1 of 12 omb no. Or contact your local social security office.
The form you are looking for is not available online. Application for retirement insurance benefits. An appointment is not required but if you call ahead and schedule one it may reduce the time you spend waiting to apply. Check x whether you are female.
Enter your social security number 3. Social security administration retirement survivors and disability insurance. Please call us at 1 800 772 1213 tty 1 800 325 0778 monday through friday between 8 a m. Application for child s insurance benefits.
The information you provide will be used by the social security administration to determine if you or a dependent is eligible to insurance coverage and or monthly benefits. Your employer doesn t need to sign section b of the cms l564 form. Page 1 of 9 omb no. State i want part b coverage to begin mm yy in the remarks section of the cms 40b form or the online application.
Visit faq ssa gov or call social security to free at 1 800 772 1213 tty 1 800 325 0778 for more information. Application for widow s or widower s insurance benefits do not write in this space with this application you are applying for all insurance benefits for which you are eligible under. Social security number i am the spouse of the person named below who has applied for insurance benefits under title ii of the social security act as presently amended. Ssa 10 10 2019 uf discontinue prior editions.
Do not write in this space 1. With this application you are applying on behalf of the child or children listed in item 3 below for all. Please tell us about your work since. Many forms must be completed only by a social security representative.
I apply for all insurance benefits for which i am eligible under title ii federal old age survivors and disability insurance and part a of title xviii health insurance for the aged and disabled of the social security act as presently amended. Form ssa 4 bk 01 2017 uf discontinue prior editions social security administration. First name middle initial last name 2.
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