Form Tftrc1000ge - Enrollment Form (Ny Residents) - Ams Insurance Program (Page 2 of 2) in pdf

TRICARE

Member

Check

the box(es) at left if you and/or your Spouse use TRICARE Prime.

Prime User?

Spouse

We’ll rush you full details about AMS TRICARE Prime Supplement Insurance Plan.

6. Please read carefully; then sign and return your completed Form to us with your initial premium payment.

I hereby certify that the above statements are complete and true to the best of my knowledge. I hereby elect to apply for insurance indicated under the AMS

TRICARE Supplement program,

underwritten by Transamerica Financial Life Insurance

Company. I understand that my coverage will become effective the first of

the month following your receipt of my acceptance certificate and first premium payment.

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.

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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Signature

date

Signature of Spouse

date

(If applying for coverage.)

10/11

Complete the following section, if you wish to pay your premiums via automatic Electronic Funds Transfer (EFT) From your Checking account:

PAYOR’S AUTHORIZATION TO FINANCIAL INSTITUTION

I hereby request and authorize you to pay and charge to my account electronic premium debits by AmWINS Group Benefits, Inc., Irving, Texas, provided there are sufficient

collected funds in my account. I agree that this electronic debit shall be regarded in the same respect as if this were a check drawn on my account and signed by myself. This authority is to remain in

effect until revoked by me in writing.

PAYOR’S AUTHORIZATION TO PLAN ADMINISTRATOR

BANK INFORMATION

PLEASE PRINT ALL INFORMATION ExCEPT SIGNATURE

Banking Institution:

Branch

Address of Branch:

City:

State:

Zip Code:

Account Number:

Name of Account (Payor’s Name):