Supplement Plan Enrollment Form
ADVERTISEMENT
1
2
3RAUS Group TRICARE Prime
Please Leave Blank
Ref. No.
Supplement Plan Enrollment Form
Underwritten by: Transamerica Financial Life Insurance Company, Harrison, NY, an AEGON company
Policy Holder: American Military Insurance Trust
Organization: Retired Association of the Uniformed Services
Check the appropriate box:
New Enrollment Form
Add Dependent(s)
Change Coverage
Member’s Name ________________________________________________________________
CHECK ONE
Mr.
Mrs.
Ms.
First
M.I.
Last
RETIRED
Address _______________________________________________________________________
WIDOW/ER
FORMER SPOUSE
City _______________________________________ State _____________Zip ______________
Date of Birth _______________Rank and Service _____________ Military Retirement Date __________________
Mo.
Day
Yr.
Telephone No. __________________________________________________________________________________
Home
Offi ce
MO.
DAY
YR.
Name of each dependent for whom coverage is desired:
Spouse __________________
Date of Birth
MO.
DAY
YR.
MO.
DAY
YR.
Child _______________________
Child ____________________
Date of Birth
Date of Birth
MO.
DAY
YR.
MO.
DAY
YR.
Child _______________________
Child ____________________
Date of Birth
Date of Birth
I have checked the coverage I desire below and am enclosing a check for $ ________________ in payment of __________
quarter(s). Check the brochure for the appropriate premium schedule.
YOU MUST BE ENROLLED IN TRICARE PRIME TO ENROLL IN ONE OF THE FOLLOWING PLANS
Retired Member
Spouse of Retired Member
Each Child of Retired Member
Plan A
Plan A
Plan A
Plan B
Plan B
Plan B
I hereby enroll myself and/or my dependents with the Transamerica Financial Life Insurance Company for coverage under
the RAUS group health program. I understand that I must be a member of RAUS to be eligible for coverage and that my
coverage will become effective on the fi rst day of the month following receipt of this enrollment form and premium.
I understand that any injury or sickness, whether diagnosed or undiagnosed, for which any person proposed for coverage
has received medical treatment or care within the 6 months immediately preceding their effective date will not be covered
until the coverage has been in effect for 6 months. I further understand that new conditions will be covered immediately.
NY Residents: Any person who knowingly and with intent to defraud any insurance company or other person fi les 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 shall also be subject to a civil penalty not to exceed fi ve thousand dollars and the stated value of the claim
for each such violation.
Date _______________________ Member’s Signature (X) ___________________________________________________
Date _______________________ Spouse’s Signature (X) ____________________________________________________
(If applicable)
Signature of Agent (X) _______________________________ Agent No. _____________General Agency No. ___________
PRINT: Name of Agent ______________________________________ Phone No. _______________________________
Agent’s Address _______________________________________________________________________________
(See reverse side for partial list of services and cost share amounts)
RAUS 183-4/10
MLTRC1000GE
19466681
MZ0925772H0000A
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business