Form Tftrc1000ge - Enrollment Form (Ny Residents) - Ams Insurance Program printable pdf download

AMS TRICARE Supplement Plan

Enrollment Form (New York Resident)

Underwritten by: Transamerica Financial Life Insurance Company,

Home Office: 440 Mamaroneck Avenue, Harrison, New York 10528, a Transamerica Company.

Policyholder:

Group Policy Number: MZ0926079H0000A

American Military Society

1. Please fill in as required

First Name

Last Name

Branch

of Service:

Member Number

Address

(if applicable):

Rank/Grade:

Date of

Sex:

City

Birth:

Home Phone:

(

)

State

Zip

Work Phone:

(

)

County of Residence:

MWEBP

2. Please complete this section ONLY if you want coverage for your Spouse and/or Children.

Spouse’s Full Name:

Spouse’s Date of Birth:

(if coverage is selected):

Child’s Name:

Child’s Sex:

Child’s Date of Birth:

(if coverage is selected):

Child’s Name:

Child’s Sex:

Child’s Date of Birth:

(if coverage is selected - if additional space is needed, attach a separate piece of paper):

Are you currently enrolled in CHAMPVA?

Yes

Check

the appropriate boxes to indicate the coverages you want for yourself and each person you want covered.

YOUR MONTHLY PREMIUM RATES *

RETIREE AND FAMILY

$150/$300 Plan Deductible

$300/$600 Plan Deductible

Age

Male

Female

Age

Male

Female

Under 40

$26.73

$28.43

Under 40

$17.38

$18.48

40 - 44

$27.80

$29.37

40 - 44

$18.08

$19.09

45 - 49

$31.75

$32.12

45 - 49

$20.65

$20.89

50 - 54

$39.55

$40.52

50 - 54

$25.71

$26.35

55 - 59

$49.02

$51.06

55 - 59

$31.86

$33.19

60 - 64

$54.91

$57.29

60 - 64

$35.70

$37.24

All Children

$24.70

$16.06

Spouse:

$10.48

Each Child

$9.63 There is no Plan Deductible.(Billed Semi-Annually)

ACTIVE DUTY DEPENDENTS:

* Rates and/or benefits may be changed on a class basis. Rates are based on the attained age of the Insured Person and increase as you enter each new age category.

Please select the mode of payment most convenient for your budget.

EFT** - Monthly

Quarterly

Semi-Annually

Annually

Electronic Funds Transfer: For your personal convenience, you can -- if you wish -- pay your premiums automatically by Electronic Funds Transfer. Use the EFT Authorization Form on

the reverse side to ensure convenient, uninterrupted protection.

If you choose to make payment by EFT, please include two (2) months’ premium as your initial payment. This is necessary to allow sufficient time for your banking institution to

arrange automatic deduction monthly, according to your instructions on the EFT Authorization Form.

▼ IF PAYINg PReMIUMS bY eFT, PLeASe FILL OUT ANd SIgN OTHeR SIde OF THIS AUTHORIzATION ▼

TFTRC1000ge

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