Form Tftrc1001ge - Group Tricare Prime Supplement Plan Enrollment Form
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1
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3Group TRICARE Standard/Extra Supplement Plan Enrollment Form (FOR NY RESIDENTS ONLY)
Underwritten by Transamerica Financial Life Insurance Company, Harrison, NY.
ORGANIZATION: GEA (Government Employees 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
Military Retirement Date ____ /____ /____
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:
Retired Member ..............................................................................
High Option II Retiree Plan
Spouse of Retired Member .............................................................
High Option II Retiree Plan
Each Child of Retired Member .......................................................
High Option II Retiree Plan
Spouse of Active Duty Member ......................................................
Active Duty Family II Plan
Each Child of Active Duty Member .................................................
Active Duty Family II Plan
I hereby enroll myself and/or my dependents with the Transamerica Financial 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.
NY 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 shall
also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.
_______________________________________________________________ Date____ /____ /____
Member Signature
_______________________________________________________________ Date____ /____ /____
Spouse Signature
TFTRC1001GE
(0115) 1057644
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