Form Tftrc1001ge - Group Tricare Prime Supplement Plan Enrollment Form Page 2
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3Government Employees Association | Membership Application
Government Employees Association (GEA) is a non‐profit, tax‐exempt organization; incorporated in 1965 in Washington, D.C.
GEA was established to provide active and retired federal, state and local government employees and spouses of employees
(including members of the military and National Guard services) with a network of resources including access to valuable
insurance plans.
APPLICANT INFORMATION
Name
Male
Married
Date of Birth ___ /___ /___
Female
Single
Employer
Occupation & Grade
Civilian
Military
Address
City
State
Zip
Preferred Email
Home Phone ( )
Work Phone ( )
Number
Spouse Name
Spouse Date of Birth ___ /___ /___
of Children _____
MEMBERSHIP TYPE
GEA Membership
$2.00 Per Month
Please note: If you are currently participating in a GEA sponsored insurance program, dues will be billed along with your insurance premiums.
I affirm that I am actively employed or retired from federal, state, or local government or military service (including the
National Guard), or I am the spouse or child, at least age 21, of a GEA member.
Member Signature
__________________________________________________________ Date____ /____ /____
Spouse Signature
__________________________________________________________ Date____ /____ /____
Send your application to:
Selman & Company
ATTN: GEA Membership
6110 Parkland Boulevard
Cleveland, OH 44124
State | Federal | Military | Local | Civilian
1214APP (GEA)
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