Form Mltrc1001ge -Group Champva Supplement Plan Enrollment Form
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1
2Group CHAMPVA Supplement Plan Enrollment Form
Underwritten by Transamerica Premier Life Insurance Company, Cedar Rapids, IA.
ORGANIZATION: AMRA (American Military Retirees Association)
Return completed form to the plan administrator: Selman & Company | 6110 Parkland Blvd | Cleveland, OH 44124 | Fax: 800.311.3124
MEMBER INFORMATION
Member’s Name
Association ID#
Date of Birth ____ /____ /____
Social Security Number
Address
City
State
Zip
Home Phone (
)
Work Phone (
)
Email
Rank and Service
DEPENDENT INFORMATION
Spouse Name
Date of Birth ____ /____ /____
Female
Male
Child Name
Date of Birth ____ /____ /____
Female
Male
Child Name
Date of Birth ____ /____ /____
Female
Male
Child Name
Date of Birth ____ /____ /____
Female
Male
COVERAGE SELECTION
I have selected my coverage below and I am enclosing a check for $__________ in payment of my first quarterly premium.
Check the brochure for the appropriate premium schedule. Remember to complete the Automatic Payment Option Form.
Select Coverage:
Spouse of Disabled Veteran
Each Child of Disabled Veteran
I hereby enroll myself and/or my dependents with the Transamerica Premier Life Insurance Company for coverage under the
Association TRICARE Supplement Insurance Plan. I understand that I must be a member of the Association and that coverage
will become effective on the first 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. After 6 months from that person's effective date, he or she will become covered regardless of any
preexisting conditions he or she may have. I further understand that new conditions will be covered immediately.
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.
_______________________________________________________________ Date____ /____ /____
Member Signature
_______________________________________________________________ Date____ /____ /____
Spouse Signature
Walter Markovsky
Agent: 3671
MLTRC1001GE
(1114) 980398
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