Please print in ink or type. Do not use correction fluid or gel pens. Initial and date any changes. TO APPLY: Send this completed application with you

Transcription

1 Please print in ink or type. Do not use correction fluid or gel pens. Initial and date any changes. TO APPLY: Send this completed application with your premium check payable to: NARFE GROUP INSURANCE PROGRAM P.O. BOX Des Moines, IA QUESTIONS? Call: Are you now a member of National Active and Retired Federal Employees Association? G Yes G No Membership # Yes. Enroll me in the cancer care plan. Member: Add 1: Add 2: City, St., Zip: CANCER INSURANCE PLAN APPLICATION Last First MI FOR RESIDENTS OF AL, AZ, DC, GA, HI, IA and OH Transamerica Premier Life Insurance Company 4333 Edgewood Road N.E. Cedar Rapids, IA Member's Date of Birth / / Gender G Male G Female PHONE NUMBERS: Home ( ) 1. Select your coverage: Check one box: Monthly Premiums* Member's Age Member & Spouse Family Member Only Under 65 G $19.15 G $20.77 G $ G $31.03 G $33.80 G $ & Over G $38.05 G $41.24 G $19.80 Work ( ) Fax ( ) 2. If, in addition to yourself, you are applying for family coverage, complete below as applicable. Dependent Name (name if proposed for insurance) DATE OF BIRTH GENDER G Male G Female Dependent Name (name if proposed for insurance) G Male G Female CA187E 7 STATES 1 # /31337/ 1018/

2 3. Please read, sign and date: To the best of your knowledge and belief, have you or your dependents (if applying for dependent coverage) ever received treatment or been medically advised of Cancer (excluding Skin Cancer), Leukemia or Hodgkin's Disease during the last 10 years, 2 years in GA? G Yes G No (Treatment means medical and surgical care by a licensed provider to detect or cure Cancer. This includes examination, diagnostic procedures, surgery (including pre- and post-operative care), prescribed medication and the application of remedies and therapy. It does not include any diagnostic procedures or examinations performed to monitor a previous removal or remedy of Cancer, provided there is no positive diagnosis of Cancer or of a recurrence of Cancer.) If you answered "Yes," please indicate the name(s) of the person(s) and their corresponding medical condition(s). It is understood that any person listed above will not be eligible for coverage except any person listed with Skin Cancer. Any person listed with Skin Cancer will be eligible for coverage. Benefits, however, will not be payable for Skin Cancer during the first 12 months of coverage. It is understood that no benefits will be payable for expenses incurred during the first 12 months of coverage for any cancer diagnosed or treated within the first 30 days after the insured person's effective date of coverage (not applicable to residents of AZ). Your coverage will be effective on the first day of the month following acceptance of your application, provided your first premium is paid and you are not hospital-confined on that date. Are you or any dependents eligible for Medicare? Yes No Notice to Consumer: THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. ALSO, THE BENEFITS PROVIDED BY THIS POLICY CANNOT BE COORDINATED WITH THE BENEFITS PROVIDED BY OTHER COVERAGE. PLEASE REVIEW THE BENEFITS PROVIDED BY THIS POLICY CAREFULLY TO AVOID A DUPLICATION OF COVERAGE. NOTICE: This policy may only be issued if you have minimum essential coverage within the meaning of section 5000A(f) of the Internal Revenue Code, or you are treated as having minimum essential coverage due to your status as a bona fide resident of any possession of the United States pursuant to Code section 5000A(f)(4)(B). If you have employer-sponsored coverage, COBRA coverage, insurance purchased from DC Health Link, Medicare, or other similar insurance, you likely have minimum essential coverage. If your minimum essential coverage is terminated for any reason, you should notify the company immediately. Questions (1), (2), and (3) below are not required for applicants age 65 or older. (1) Do you have comprehensive medical coverage including the minimum essential coverage required by the Affordable Care Act (ACA) or are you treated as having minimum essential coverage due to your status as a bona fide resident of any possession of the United States? G Yes G No If you answered NO to question 1, you are not eligible for this policy, in the form of hospital or fixed indemnity insurance. (2) Do you understand most supplemental only policies may not pay full benefits if your ACA compliant minimum essential coverage plan is not in force? G Yes G No (3) Do you understand that the benefits provided under this policy may be limited? G Yes G No Signature of Applicant X Signature of Spouse X (if applying) Date X Date X DC and OH Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of 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. CA4000GAMR1015 July 2017 *If applicable, an additional $2 billing fee will be included on your billing notice payable to the administrator. To save the fee, select Electronic Funds Transfer (EFT) as a safe and secure payment option. MZ H0000A * * CA187E 7 STATES 2 #

3 Cancer Insurance Plan For National Active and Retired Federal Employees Association Members and Their Families PROTECTING YOURSELF According to the Cancer Facts and Figures 2017, in the US, men have slightly less than a 1 in 2 lifetime risk of developing cancer; for women, the risk is a little more than 1 in 3.* Fortunately, advances in cancer treatment are saving more lives than ever before. With these advances in care, however, come rising health care costs. There can be hospital expenses, specialists' fees, prescription drugs, operations, day and night nursing care, therapists...and more. This plan may provide you with cash benefits to help cover the costs of cancer treatment and other incidental costs. That means it pays you benefits regardless of any other coverage you have. *These statistics have been made available by "Cancer Facts and Figures, 2017." WHAT YOU CAN DO ABOUT IT 1. Take Charge No one has a greater stake in your health care than you do. Do not be passive and don't accept everything you're told. Educate yourself and ask questions. The most helpful is to ask your doctors: "What would you do if you were me?" 2. Have More than One Source of Help The problems that come with fighting cancersearching for research hospitals, managing symptoms and side effects, understanding what the specialist is sayingall are more difficult when you don't have enough money. Many NARFE members and their families rely on the NARFE Cancer Insurance Plan as a second source of help. You can, too (if you haven't had cancer in the past 10 years). It covers you, plus your spouse and children under age 19 (under age 22 if full-time student) when you select family coverage. Please note: dependent eligibility ages vary by state. Your Certificate/Policy will provide the full details. You can go anywhere in the U.S. for care and use whatever doctor you choose. There are no networks or lists of "preferred providers." Once your application is approved, your coverage becomes effective on the first of the month after you've paid your first premium. Your rates won't increase if you get cancer, and your coverage can't be canceled as you get older. The only way your rates will increase is if they are increased for everyone in the group, no matter how many claims you submit. And your protection will never be canceled as long as the master policy stays in force for the entire group, you pay your premiums and you remain a NARFE member. Transamerica Premier Life Insurance Company has the right to increase premiums on any premium due date with 31 days notice to you, rates may increase if the group master policy changes. The NARFE Cancer Insurance Plan Pays Cash Benefits Directly to You or to Anyone You Choose And It Pays REGARDLESS OF Other Coverage You Have Hospital Confinement$ daily per illness period, days Extended Hospital Expense100% of hospital charges in lieu of any other benefits up to $6, a month after 90 consecutive days. If you leave the hospital and then return within 45 consecutive days, as is common, your benefit period picks up from your last "benefit day." Private Duty Nurse$30.00 daily to $ per illness period for private duty nursing care while hospitalized for cancer. Attending Physician$20.00 daily for doctor's visits(other than your surgeon) while in the hospital. Surgical10% of actual charges up to $1, per operative session. No limit on the number of surgeries covered. Anesthesia$ per operative session, except skin cancer, for which you receive $40.00 per removal session. No limit on the number of procedures. Blood & Plasma$ per illness period for pints of blood and plasma costs. No limit for leukemia up to the overall lifetime maximum. Chemotherapy & Radiation$1, per illness period (including x-ray, radium and cobalt treatments). Skin Cancer RemovalMaximum benefit of $62.50 for the initial incision, $25.00 per additional incision. Ambulance Service$50.00 for each ambulance one way trip to or from the hospital or skilled nursing facility maximum per illness $500. Second Opinion Benefit$ per illness period to receive a second medical opinion about your initial cancer diagnosis. First Occurrence$1, for one time only if you are diagnosed as having cancer. (Excludes skin cancer.) Miscellaneous Hospital Expense$1, per illness period for drugs, medicine and medical supplies necessary for the treatment of cancer. The lifetime maximum amount for all above benefits is $500, Termination of Coverage. Coverage ends if: the Master Policy is terminated; the member is no longer a member of his/her association; or the insured fails to pay the appropriate premium. Dependent's coverage ends when member's coverage ends, its premiums are not paid, the Master Policy is terminated, or on the premium due date coinciding with or next following the date the dependent ceases to be eligible. CA187PA #

4 How to Apply 1. Complete the enclosed application. 2. Mail it in the postage-paid envelope to: ADMINISTRATOR NARFE GROUP INSURANCE PROGRAM P.O. Box Des Moines, IA Be sure to include your first quarterly premium payment payable to NARFE Insurance Services. Your Payment Options Please note: You also may have the option of paying your premiums once a year (annually), twice a year (semi-annually), or four times a year (quarterly). If you pay your premiums monthly, quarterly or semi-annually, the total amount of premiums and/or administration fees that you pay in a year may be higher than if you make one annual payment. If you are interested in learning more about these payment options, please refer to your fulfillment package for details. All billing modes except annual will include a $2.00 billing fee. To avoid the fee, select EFT as a safe and secure payment option. QUESTIONS? Once you receive your Certificate, take 30 days to look it over. If you decide the NARFE Cancer Insurance Plan isn't for you, simply return it within 30 days and receive full refund of any premiums paid. Researched and Tailored for our Members Exclusions Benefits will not be paid under this Policy and any attached Rider for any expenses which result from:. injury or sickness other than Cancer;.expenses the Cover Person is not legally obligated to pay or those charged only because you have insurance;. treatment or services preformed outside of the United States. Pre-existing Condition Limitation No benefits will be payable for the Covered Person's Pre-Existing Conditions. They are defined as a Cancer that was positively diagnosed within 10 years prior to the Covered Person's Effective Date of Coverage under the Group Policy, or a Cancer for which treatment has been received before the Covered Person has been insured for 30 days from his Effective Date of Coverage (N/A in AZ). We will, however, pay benefits for Cancer diagnosed and treated within the first 30 days the Covered Person has been insured only if incurred after coverage has been in force for 12 consecutive months from the Effective Date. Any increase in benefits will be subject to a new Effective Date of Coverage on that increased amount or benefits only. A Notice About Transamerica's Privacy Policy Please visit Administered by: Mercer Consumer, a service of Mercer Health & Benefits Administration LLC P.O. Box Des Moines, IA AR Insurance License # CA Insurance License #0G39709 In CA d/b/a Mercer Health & Benefits Insurance Services LLC Other insurance in this company: Only one certificate or policy providing Cancer coverage may be in force as elected by the member. If any other certificate or policies previously issued by us or any other AEGON, U.S.A. affiliates are in force concurrently with the Certificate issued under this policy, the excess insurance will be void. All premiums paid for the excess will be returned to the Insured. THIS IS A CANCER ONLY POLICY Underwritten by: 4333 Edgewood Road N.E. Cedar Rapids, IA This brochure provides a brief description of the benefits available. Complete details may be found in Group Policy Form No. CA 1000GPM, Policy No. MZ H0000A, Certificate Form No. CA1000GCM.series. Benefits may vary by state. Coverage may not be issued to residents of all states. You'll be billed quarterly. Copyright 2017 Mercer LLC. All rights reserved. July 2017 * * CA187PA #

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