TRICARE GEA. Medicare Eligibility. also a plan for your Dependents. See chart below. continues. Plan: Former spouses

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1 GEA TRICARE Supplement Plan for FEHB and Postal Employees GET THE PROTECTION YOU MAY NEED, AT A COMPETITIVE PRICE. The TRICARE Supplement Plan for FEHB and Postal Employees provides benefitss to help pay your TRICARE cost share for inpatient and outpatient care including doctor visits, emergency room care and prescription medications. The TRICARE Supplement Plan for FEHB and Postal Employees also pays 100% of Covered Excesss Charges up to the TRICARE Legal Limit. If you are an Active Duty Member, there is also a plan for your Dependents. See chart below. Plan Sponsor: Government Employees Association (GEA) The Government Employees Association is a non profit, tax exempt organization; incorporated in 1965 in Washington, D.C. GEA was established to provide active and retired federal, state and local government employees (including members of the military and National Guard services) with a network of resources. Important Notice This coverage is available to GEA members and their dependents. If you are nott already a GEA member, please complete the enclosed GEA G membership application. The $36.00 per year membership dues will be added to your insurance premium according to the payment option you select. Continued membership and benefit enjoyment requires renewal of membership upon expiration of the initial period. For additional inquiries, call Selman & Company, the plan administrator, toll free at: Who is Eligible to Enroll in the TRICARE Supplement Plan All retired uniformed service members who are eligible for TRICARE, not eligiblee for Medicaree and under age 65, including: Military retirees who are entitled to retired pay and their spouses/surviving spouses who are not eligible for Medicare. Retired Reservists and National Guardsmen between the ages of 60 and 65 with 20 years of creditable service and their spouses/surviving spouses who are not eligible for Medicare. Retired Reservists and National Guardsmen under age 60 and enrolled in TRICARE Retired Reserve (TRR) and their spouses/surviving spouses are not eligible for Medicare. Military retirees and their spouses/surviving spouses who reside outside the U.S. or its territories ( all who are eligible for Medicare must be enrolled in Medicare). Military retirees and their spouses/surviving spouses age 65 or older but ineligible for Medicare (all must have received a Statement of Disallowance from Social Security Administration). Medicare Eligibility Individuals who are eligible for Medicare are ineligible for enrollment in the TRICARE Supplement Plan. Eligibility for the supplement plan ends when an individual becomes eligible for Medicare. Dependent Eligibility Coveragee is extended to your unmarried children: Under age 21 (23 if full time student). Age 21/23 to under age 26 if enrolled in TRICARE Young Adult (TYA) program. Incapacitate dependents may continue coverage past policy age limits as long as TRICARE eligibility continues. The following individuals and their family members are ineligible for enrollmentt in the TRICARE Supplement Plan: Active Duty spouses TRICARE Reserve Select members Former spouses To verify your eligibility for TRICARE benefits, contact the Defensee Enrollment Eligibility Reporting System (DEERS) at the following toll free number:

2 Effective Date Your coverage and that of your covered dependents becomes effective on the first day of the month following receipt of your Enrollment Form and first premium payment. If, on that day, you or a covered dependent are confined in a hospital, the effective date will be the day following discharge from the hospital. Newborn children not named in your enrollment form are automatically covered from birth for injury or sickness, including treatment of congenital defects and birth abnormalities, for 31 days. You must notify the Plan Administrator in writing and pay the additional premium due within 31 days of birth for coverage to continue beyond this period. Insured children who are incapable of self sustaining employment because of mental retardation or physical disability and who are unmarried and chiefly dependent on the insured member for support and maintenance may continue coverage past policy age limits, with requested proof. Otherwise, each dependent child's coverage terminates on the premium due date following the date he or she is no longer a dependent. There is no pre existing condition limitation under this TRICARE Supplement Plan. Benefits are payable immediately for all covered expenses. Nervous, Mental, Emotional Disorder Alcoholism, and Drug Addiction Limits The coverage provided under the Inpatient Benefits for nervous, mental, and emotional disorders, including alcoholism and drug addiction is limited to (a) 30 inpatient treatment days for Covered Person age 19 or older or (b) 45 inpatient treatment days for Covered Person age 19; per fiscal year. This Inpatient limit is based on the number of days TRICARE normally provides each fiscal year for such confinements. In rare instances, TRICARE extends these daily limits. If this occurs, we will limit the number of days that we provide for such Confinement to the lesser of (a) the number of days for such inpatient treatment during the fiscal year or (b) 90 inpatient days per fiscal year. The coverage provided under the Outpatient Benefits for (a) nervous, mental, and emotional disorders; and (b) alcoholism and drug addiction is limited to $500 during any TRICARE fiscal year for all such disorders. Exclusions and Limitations The Policy does not cover injury or sickness resulting from war or act of war, whether war is declared or undeclared; intentionally self inflicted injury; suicide or attempted suicide whether sane or insane (in Missouri while sane); routine physical exams, unless required for school enrollment (but not sports physicals) by a Covered Child aged 5 through 11 and immunizations, except that these services are covered when rendered to a Covered Child who is less than 6 years of age; domiciliary of custodial care; eye refractions and routine eye exams except when rendered to a child up to 6 years from the child s birth; eyeglasses and contact lenses; prosthetic devices, except those covered by TRICARE; cosmetic procedures except those resulting from covered Sickness or Injury; hearing aids; orthopedic footwear; care for the mentally incapacitated or physically handicapped if the care is required because of the mental incapacitation or physical handicap; drugs which do not require a prescription, except insulin; dental care unless such are is covered by TRICARE; and then only to the extent that TRICARE covers such care; any confinement, service, or supply that is not covered under TRICARE; hospital nursery charges for a well newborn, except as specifically provided under TRICARE; any routine newborn care except Well Baby Care, as defined for a child up to 6 years from his or her birth; TRICARE eligible cost share and deductible amounts in excess of the TRICARE cap; expense which are paid in full by TRICARE; treatment for the prevention or cure of alcoholism or drug addiction except as specifically provided under TRICARE and the Policy; any part of a covered expense which the Covered Person is not legally obligated to pay because of payment by a TRICARE alternative program; any claim under more than one of the TRICARE Supplement Plans or under more than one Inpatient Benefit or more than one Outpatient Benefit of the TRICARE Supplement Plans. If a claim is payable under more than one of the state Plans of Benefits, payment will only be made under the one that provides the highest coverage. Pre Existing Conditions Limitations There is no pre existing condition limitation under this TRICARE Supplement Plan. Benefits are payable immediately for all covered expenses. Termination Your coverage is renewable to age 65 as long as premiums (which includes association dues in the sponsoring organization (GEA) are paid on time; you, your spouse and dependents remain in an eligible status, and the Master Policy and your class of insured persons remain in effect. So, even if you or a covered dependent develops a serious health condition in the future; the coverage will not terminate, provided these conditions are met. Non Duplication of Coverage under Employer Health Program If a claim payable under the Policy is also payable under an Employer Health Program with TRICARE as the secondary payor, we will limit our payment to an amount which, when added to the amounts paid by the Employer Health Program and TRICARE, will not exceed 100% of TRICARE Covered Expenses.

3 HERE S HOW THE COMPREHENSIVE TRICARE SUPPLEMENT WORKS TO PAY AFTER TRICARE HAS PAID Care Required INPATIENT FACILITY SERVICES in civilian hospitals for RETIREES and their dependent family members (room, board, supplies, and staff services billed by the hospital). INPATIENT PROFESSIONAL SERVICES in civilian hospitals for RETIREES and dependent family members (doctors, and other inpatient services not billed by the hospital). TRICARE Standard/Extra Pays THE TRICARE Standard/DRG allowed amount (contracted rate for TRICARE Extra minus your cost share). 75% of the TRICARE Standard allowed amount (80% for TRICARE Extra) for doctors and other professional services. After TRICARE Standard/Extra Pays, The Supplement Pays The lesser of $708 per day or 25% of the billed amount, not to exceed the TRICARE Standard DRG amount (lesser of $250/day or 20% cost share of the contracted rate for TRICARE Extra). Your 20% Extra or 25% Standard cost share. TRICARE Prime/Point Of Service (POS) Pays PRIME All but the Prime copayments POS 50% of the TRICARE allowed amount. PRIME All but the Prime copayments. POS 50% of the TRICARE allowed amount. After TRICARE Prime/POS Pays, The Supplement Pays PRIME All Prime copayments. POS The 50% POS cost share. PRIME All Prime copayments. POS The 50% POS cost share. INPATIENT CARE in military hospitals. All but the daily subsistence fee. The daily subsistence fee. The daily subsistence fee. The daily subsistence fee. OUTPAITENT CARE for RETIREES and their dependent family members (office visits, clinics, lab, etc.) 75% of the TRICARE Standard allowed amount (80% for TRICARE Extra) after you pay for the TRICARE Outpatient Deductible. Your 20% Extra or 25% Standard cost share, 50% of the deductible amount of $150 individual (maximum $300 family) PLUS 100% of charges in excess of the TRICARE Standard allowed amount, if applicable. PRIME All but the Prime copayments. POS 50% of the TRICARE allowed amount after the deductible has been met. PRIME All Prime copayments. POS The 25% POS cost share and 50% of the POS deductible * of $300 per person or $600 per family PLUS 100% of Covered Excess Charges up to the billed amount. PRESCRIPTION DRUGS (civilian network pharmacy) up to a 30 day supply. All but $8 generic, $20 brand name or $47 non formulary copayment. All copayments. All but the $8 generic, $20 brand name or $47 non formulary copayment. PRIME All prime copayments. PRESCRIPTION DRUGS (Home Delivery) up to a 90 day supply. All but $16 brand name or $46 non formulary copayment. All copayments. All but the $16 brand name or $46 non formulary copayment. PRIME All prime copayments PRESCRIPTION DRUGS (civilian non network Pharmacy up to a 30 day supply). All but the TRICARE deductible and $20 (20% generic/brand name) or $47 (20% nonformulary) copayment, whichever is greater. $20/20% or $47/20% Standard cost share PLUS 50% of the TRICAER deductible of $150 individual (maximum $300 family). Not Applicable. POS The 25% POS cost share and 50% of the POS deductible* of $300 per person or $600 per family. *Reimbursement toward the fiscal year TRICARE Standard Outpatient Deductible is made only if the deductible is incurred after the effective date of coverage. **Diagnosis Related Group established standard hospital stays for categories of medical conditions. Note: The TRICARE Supplement Plan pays the TRICARE approved expenses after TRICARE has paid and you have met 50% of the TRICARE Standard Outpatient Deductible. Note: Benefits are payable for covered cost share amounts up to the TRICARE Catastrophic Cap. Exclusions may vary by state and underwriter. See your Certificate for complete detail. This is not a Medicare supplement insurance. For more information about Medicare and Medicare Supplement insurance, review the Guide to Health Insurance for People with Medicare, available from the insurance company.

4 INSURANCE PREMIUM RATE CHART Competitively Priced Premiums to Fit Your Budget Monthly Premium Rates Retirees *Premiums shown are monthly Child Only $70.50 Spouse Only $70.50 Member Only $70.50 Two/More Children $ Member plus Child (ren) $ Spouse plus Child (ren) $ Member Plus Spouse $ Member Plus Family $ As a member, the rates for this valuable coverage more competitive. What's more, the insurance company guarantees you'll never be singled out for a rate increase, no matter how many claims you file. 1 1 Rates and/or benefits are based on the attained age of the Insured Person and increase as you enter each new age category. Rates and/or benefits may be changed on a class basis. Plan or rate changes may be subject to final approval by the applicable regulatory authorities. Change of Policy Premiums We have the right on each Premium Due Date to change the rate at which premiums will be calculated. This includes the right to change premium rates for a benefit that applies to all individuals of the same class, age, plan and effective date. Rates may be changed based on claims experience of the Policy. We will give the Policyholder or Organization notice of any change at least 45 days before the Premium Due Date on which it is to become effective. Change in Status If you have a change in status, such as a marriage or divorce, you gain a dependent, or your dependent reaches the maximum age limit, you must contact Selman & Company within 60 days of your change in status. If the change in status affects your premium, the new TRICARE Supplement premium will become effective as soon as practicable after reporting your change in status. You will be required to complete a new enrollment form if the change in status is to add a spouse or new dependent. Coverage for a spouse or dependent child terminates on the premium due date following the date he or she no longer satisfies the requirements to be a spouse or dependent. Newborn Children Newborn children not named on your enrollment form are automatically covered form birth for injury or sickness, including treatment of congenital defects and birth abnormalities for 31 days. You must notify Selman & Company within 31 days following the child s effective date to continue coverage before the date. Exclusions This Policy does not cover 1) injury or sickness resulting from war or act of war, whether war is declared or undeclared; 2) intentionally selfinflicted injury; 3) suicide or attempted suicide, whether sane or insane (in Colorado and Missouri while sane); 4) routine physical exams and immunizations, except when: a) rendered to a child up to 6 years from the child s birth; or b) ordered by a Uniform Service: i) for a Covered Spouse or Child of an Active Duty Member; ii) for such spouse or child s travel out of the United States due to your assignment; 5) domiciliary or custodial care; 6) eye refractions and routine eye exams except when rendered to a child up to 6 years from the child s birth; 7) eyeglasses and contact lenses; 8) prosthetic devices (except that artificial limbs and eyes and devices which must be implanted by surgery are covered); 9) cosmetic procedures, except those resulting from Sickness or Injury; 10) hearing aids; 11) orthopedic footwear; 12) care for the mentally incapacitated or physically handicapped if the care is required because of the mental incapacitation or physical handicap or the care is received by an Active Duty Member s child who is covered by the Program for the Handicapped under TRICARE; 13) drugs which do not require a prescription, except insulin; 14) dental care unless such care is covered by TRICARE, and then only to the extent that TRICARE covers such care; 15) any confinement, service, or supply that is not covered under TRICARE; 16) Hospital nursery charges for well newborn, except as specifically provided under TRICARE; 17) any routine newborn care except Well Baby Care, as defined, for a child up to 6 years from the child s birth; 18) expenses in excess of the TRICARE Cap; 19) expenses which are paid in full by TRICARE; 20) any expense or portion thereof, applied to the TRICARE Outpatient Deductible; 21) treatment for the prevention or cure of alcoholism or drug addiction except as specifically provided under TRICARE; 22) any part of a covered expense which the Covered Person is not legally obligated to pay because of payment by a TRICARE alternative program; 23) any claim under more than one of the TRICARE Supplement Plans, or under more than one Inpatient Benefit or more than one Outpatient Benefit of the TRICARE Supplement Plans. If a claim is payable under more than one of the stated Plans or Benefits, payment will only be made under the one that provides the highest coverage, subject to the Pre Existing Condition Limitation.

5 Exclusions for the State of New York The Policy does not cover: 1) injury or sickness resulting from war or act of war, whether war is declared or undeclared; 2) intentionally selfinflicted injury; 3) suicide or attempted suicide; 4)custodial care; 5) eye refractions and routine eye exams except when rendered to a child up to 6 years from the child s birth; 6) eyeglasses; 7) cosmetic surgery, except that cosmetic surgery shall not include reconstructive surgery when such surgery is incidental to or follows surgery resulting from trauma, infection, or other diseases of the involved part, and reconstructive surgery because of a congenital disease or anomaly of a covered dependent child which has resulted in a functional defect; 8) hearing aids; 9) dental care or treatment, except for such care or treatment due to accidental injury to sound natural teeth within 12 months of the accident and except for dental care or treatment necessary due to congenital disease or anomaly; 10) any confinement, service, or supply that is not covered under TRICARE; 11) expenses in excess of the TRICARE Cap; 12) expenses which are paid in full by TRICARE; 13) any expense or portion thereof, applied to the TRICARE Outpatient Deductible; 14) treatment for the prevention or cure of alcoholism or drug addiction except as specifically provided under TRICARE; 15) any part of a covered expense which the Covered Person is not legally obligated to pay because of payment by a TRICARE alternative program; 16) any claim under more than one of the TRICARE Supplement Plans, or under more than one Inpatient Benefit or more than one Outpatient Benefit of the TRICARE Supplement Plans. If a claim is payable under more than one of the stated Plans or Benefits, payment will only be made under the one that provides the highest coverage, subject to the Pre Existing Condition Limitation. Termination Insured Person: Coverage under the Policy will cease on the first to occur of: 1) the date the Policy terminates, or the date the Organization ceases to be a Participating Organization of the policyholder, 2) the date the required premium is not paid, subject to the Grace Period provision; 3) the first day of the month on or next following the date you cease to be a member of the Policyholder; 4) the first day of the month on or next following the date you cease to be eligible for the Plan under which you are covered; 5) the date we or the Policyholder cancel coverage for a Class of Eligible Person to which you belong; 6) the date you attain age 65; 7) the date you cease to be covered under TRICARE; 8) the date you become eligible for Medicare unless you reside in an area where Medicare is not available, in which case coverage will not terminate until you return to residency in an area where Medicare is available. Termination of coverage will be without prejudice to any claim which originated before the effective date of termination. Dependent: Dependent s coverage under the Policy will cease on the first to occur of: 1) the date the Policy terminates; 2) the date the required premium is not paid, subject to the Grace Period provision; 3) the first day of the month on or next following the date the dependent ceases to be an Eligible Spouse or an Eligible Child; 4) the first day of the month on or next following the date the dependent ceases to be eligible for the Plan under which the dependent is covered; 5) the date we or the Policyholder cancel coverage for a Class of Eligible Person to which the dependent belongs; 6) the date you cease to be covered, subject to the Covered Dependent Continuation provision (this will not apply to the Spouse or Child of an Active Duty Member or a Service Disabled Member); 7) the date the dependent becomes eligible for Medicare unless the dependent resides in an area where Medicare is not available, in which case coverage will not terminate until the dependent returns to residency in an area where Medicare is available; 8) if a child, the date the child attains age 21 or age 23 (if the child is enrolled full time at a school of higher learning); under 26 if covered by the TRICARE Young Adult Program; 9) the date a dependent ceases to be covered under TRICARE; 10) the date a dependent attains age 65. Termination of coverage will be without prejudice to any claim which originated before the effective date of termination. IT S EASY TO ENROLL AS A REMINDER: You must be a GEA member to enroll in the supplement plan. If you are already a member of GEA, please include your Member/Association ID# on the Enrollment Form for verification purposes. 1) Complete the enclosed Enrollment Form; sign and date where indicated. 2) If applicable, complete the enclosed GEA membership application; sign and date where indicated. 3) Include your first quarterly payment with your completed Enrollment Form. Quarterly premium rates are provided in the Insurance Premium Rate Chart. Make your check payable to: GEA Group Health Program. 4) For future premium insurance payments, be sure to complete the enclosed Automatic Payment Option Form. 5) Mail your completed Enrollment Form, GEA membership application (if applicable), Automatic Payment Option Form and quarterly payment to: TRICARE Supplement 1620 Main Street #5 Sarasota, FL 34236

6 SATISFACTION GUARANTEED 30 DAY FREE LOOK You cannot be turned down for coverage, although a pre existing condition may initially limit the extent of your coverage. After your completed Enrollment Form and first premium payment have been processed, you ll receive a Certificate of Insurance which you can examine for a 30 day free look. Return it for a full refund if you are not completely satisfied. Plan Administrator Selman & Company, based in Cleveland, Ohio, has marketed and administered life and health insurance products to members of associations and affinity groups, customers of financial institutions, and employees through their employers for over 30 years. Selman & Company is among the largest privately held firms in the nation with focus on the markets in which it serves. How to Contact Selman & Company Our Call Center Representatives are available if you have questions about your TRICARE Supplement Plan. memberservices@selmanco.com Plan Underwriter Transamerica Premier Life Insurance Company, Cedar Rapids, IA, Group Policy MLTRC1000GP (for all states, expect New York) Transamerica Financial Life Insurance Company, Harrison, NY, Group Policy TFTRC1000GP (for New York) This brochure explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of any discrepancy between this brochure and the contract, the terms of the contract will apply. Complete details are found in the certificate of insurance issued to each insured individual. Coverage may not be available in all states; you will be advised. (0115)

7 TRICARE SUPPLEMENT PLAN ENROLLMENT FORM FOR EXISTING AND NEW EMPLOYEES RESIDING IN NY ADMINISTERED BY: SELMAN & COMPANY SPONSORED BY: GOVERNMENT EMPLOYEES ASSOCIATION (GEA) UNDERWRITTEN BY: TRANSAMERICA FINANCIAL LIFE INSURANCE COMPANY, HARRISON, NY New Enrollment Add Dependent(s) Terminate Coverage Terminate Member Only Terminate Dependent(s) Only Change Address CHECK THE BOX BELOW IF YOU ARE: SELECT YOUR TRICARE OPTION BELOW: POLICY #: MZ H0001A Retired Military Retired Military Spouse/Surviving Spouse Retired Reservist Retired Reservist Spouse/Surviving Spouse National Guard or Reserve Member Standard Prime Retired Reserve Reserve Select (TRS) Medicare beneficiaries are not eligible to enroll. Group Code: Member ID #: (LEAVE BLANK) Coverage Effective Date: Employee SSN: - - Enroll Myself: Yes No Employee Date of Birth: Employee Last Name: Employee First Name: Middle Initial: Gender: M F Home Address: City: State: Zip Code: Home Phone: Relationship Codes Work Phone: LIST ALL DEPENDENTS TO BE ENROLLED IN THE PLAN Date of Birth Last Name First Name MI MM/DD/YYYY SSN Gender S-Spouse M F DB If Disabled Check Yes C-Child M F Yes C-Child M F Yes C-Child M F Yes C-Child M F Yes I hereby enroll myself and/or my dependents with the Transamerica Financial Life Insurance Company for coverage under the Government Employees Association (GEA) sponsored TRICARE Supplement Plan. I understand that I must be a member of GEA to be eligible for coverage and that my coverage will become effective on the receipt of this enrollment form and premium. 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. SIGN HERE EMPLOYEE SIGNATURE: DATE: Policy Series: MLTRC1000GE (0315) If paying by Electronic Funds Transfer (EFT) from your financial institution account, please complete the enclosed Automatic Payment Option Form. If paying by check, you must remember to mail your first check, with applicable dues, to: TRICARE Supplement 1620 Main Street #5 Sarasota, FL 34236

8 Automatic Payment Option (APO) Savings or Checking Account Deduction Authorization Form 1. Applicant s Information (proposed insured) Applicant s Name Date of Birth / / Street Address City State Zip Code Please list the Insurance Policy you wish to have premium deductions made from the account indicated below: Policy Number: Type of Insurance: (Office Use Only) 2. Financial Institution Information Depositor Name (Payor) (As it appears on Financial Institution Records) Financial Institution Name Account Number (Include Branch Name) Financial Institution City State Zip Code 3. Account Selection: I authorize an automatic deduction from my (please choose one): Checking Account. Attach a sample VOIDED check. Savings Account. Account Number: Routing Number: Premium deduction should be made: Monthly Quarterly Semi-Annually Annually Please include your first modal premium check made payable to Selman & Company. All subsequent premium payments will be made as indicated above. 4. Signature/Authorization In accordance with the agreements and conditions listed below, I hereby request and authorize Selman & Company to initiate debit entries on the Financial Institution account listed herein for the purpose of paying premium. This authorization is to remain in full force and effect until Company and Depository have received written notification from me of its termination in such time and manner as to afford Company and Depository a reasonable opportunity to act on such notification. Written notification must be mailed to: Selman & Company, 6110 Parkland Boulevard,Cleveland, OH Signature of Depositor Print Name of Depositor Date / / Signature of Applicant/Insured (If different from Depositor) Print Name of Insured/Applicant Date / / 5. Agreements & Conditions Automatic Payment Option (Account Deduction Authorization) is subject to the following conditions: 1. Premium payments will be debited from your account on or about the premium due date. 2. Additional premium that may be required in order to keep policy(ies)/certificate(s) current may be drawn from your account through the use of multiple debits. 3. Selman & Company (Company) may revoke the privilege of paying premium under this Automatic Payment Option (APO) if any payment is dishonored. 4. A service fee of $15.00 may be assessed for each dishonored payment. 5. Payment of premium under APO may be discontinued by the Company or the undersigned upon thirty (30) days written notice. 6. If APO is discontinued, an alternate payment mode acceptable to the Company will be used to remit the premiums needed to keep the policy(ies)/certificate(s) in force and current. 7. The Company will not send premium notices while APO is in effect. 8. A request for change or adjustment to the APO must be sent directly to the Company s Customer Service Department. 9. If you cancel this service, any refund of premium due you will take sixty (60) days to process. NOTE: Please keep a copy of this completed document for your record. OFFICE USE ONLY Insured ID: APO Effective Date: 0115 APO