Fillable Tricare Supplement Plan Enrollment Form printable pdf download

TRICARE SUPPLEMENT PLAN ENROLLMENT FORM

FOR EXISTING AND NEW EMPLOYEES

ADMINISTERED BY:

SELMAN & COMPANY

SPONSORED BY:

GOVERNMENT EMPLOYEES ASSOCIATION (GEA)

UNDERWRITTEN BY: TRANSAMERICA PREMIER LIFE INSURANCE COMPANY, CEDAR RAPIDS, IA



New Enrollment

Add Dependent(s)

Terminate Coverage



Terminate Member Only



Terminate Dependent(s) Only



Change Address

CHECK THE BOX BELOW IF YOU ARE:

SELECT YOUR TRICARE OPTION BELOW:

POLICY #: MZ0925782H0000A

Group Code: 0002824



Retired Military

Standard

Retired Reserve

Member ID #:



Retired Military Spouse/Surviving Spouse

Prime

Reserve Select (TRS)

(LEAVE BLANK)



Retired Reservist

Coverage



Retired Reservist Spouse/Surviving Spouse

Medicare beneficiaries are not eligible to enroll.

Effective Date:



National Guard or Reserve Member

Employee

Employee SSN: __ __ __-__ __-__ __ __ __

Enroll Myself:



Yes



Date of Birth:

Employee Last Name:

Employee First Name:

Middle Initial:

Gender:



Home

City:

State:

Zip Code:

Address:

Home

Work

Phone:

LIST ALL DEPENDENTS TO BE ENROLLED IN THE PLAN

Relationship

Date of Birth

If Disabled

Last Name

First Name

SSN

Gender

Codes

MM/DD/YYYY

Check Yes

Yes

S-Spouse



C-Child



Yes

C-Child



Yes



C-Child

Yes



C-Child

Yes

I hereby enroll myself and/or my dependents with the Transamerica Premier Life Insurance Company for coverage under the Government

Employees Association (GEA) sponsored TRICARE Supplement Plan. I understand that I must be a member of GEA to be eligible for

coverage and that my coverage will become effective on the receipt of this enrollment form and premium.

AR, CO, KY, LA, ME, NM, OH, OK, TN and WA Residents: Any person who knowingly and with intent to inquire, defraud, or deceive any insurer files

a statement of a claim or an application containing any false, incomplete, or misleading information is guilty of a crime and may be subject to fines

or confinement in prison. DC and RI Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or

knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. FL

Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of a claim or an application

containing any false, incomplete, or misleading information is guilty of a felony of the third degree. MD Residents: Any person who knowingly or

willfully presents a false or fraudulent claim for payment of a loss or benefits or who knowingly or willfully presents false information in an

application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NJ Residents: Any person who includes any

false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. PA Residents: Any person who

knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing

any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent

insurance act, which is a crime and subjects such a person to criminal and civil penalties.

By signing below I authorize my employer to deduct the monthly premiums from my paycheck on a pre-tax basis. I hereby authorize my

employer to reduce my gross salary before taxes are calculated according to the benefit elected.



EMPLOYEE SIGNATURE:

DATE:

SIGN HERE

Policy Series: MLTRC1000GE

(0315) 1115535

Tricare Supplement Plan Enrollment Form

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