Home What is CHAMPVA How it Works Supplement Application Contact Us Call: 1-800-242-6797 Supplement Application   Check the appropriate block: This is a new enrollment form This enrollment form is to add dependent(s) This enrollment form is to change coverage Please Leave Blank Ref No. Sponsor's Name This is the name of Veteran Mr. Mrs Ms   First M.I. Last Address  City  State  Zip CHECK ONE SPOUSE WIDOWER Date of Birth * * *   Mo. Day Yr Rank and Service  Social Security No.   TELEPHONE NO. ( )  ( )    HOME OFFICE Name of each dependent for whom coverage is desired: Spouse Social Security No. Child Male Female  */ * / * Date of Birth Child Male Female  */ * / * Date of Birth Spouse    */ * / * Date of Birth Child  Male Female  */ * / * Date of Birth Child  Male Female  */ * / * Date of Birth I have checked the coverage I desire below and am enclosing a check for $  in payment of * quarter(s). Check the brochure for premium rates. 189.3 Spouse of Sponser Each Child of Sponser Check One: I hereby enroll my spouse and/or my eligible children or I hereby enroll as a surviving spouse and/or my eligible children, with the Hartford Life Insurance Company for coverage under the AMRA CHAMPVA Group Supplement Program. I understand that I must be a member of AMRA to be eligible for coverage and that my 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. I further understand that new conditions will be covered immediately. Date  Sponsor's Signature (X) Date  Sponsor's Signature (X) SRP-1269 ENR (1969) Signature of Agent (X)  Agent No. 685-001 General Agency No. PRINT: Name of Agent  Phone No.   Agent's Address: ChampVA Supplements,1620 Main Street, #5, Sarasota, FL 34236 (COMPLETE CHECKOMATIC FORM BELOW - IF YOU WISH TO PAY PREMIUMS MONTHLY)     Optional Monthly Checkomatic Please print NAME OF THE BANK DEPOSITOR AS SHOWN ON BANK RECORDS      NAME OF INSURANCE APPLICANT (If not Bank Depositor) CERTIFICATE NO. CHECKING ACCOUNT NO. NAME OF BANK AND BRANCH ABA (BANK ROUTING NUMBER)      As convenience to me, I request and authorize Association & Society Insurance Corporation or another hartford life administrator/representative to initiate electronic debit entries each month and charge them to my checking account as indicated above. Authority to charge such debits to my account shall become effective as of the date this authorization is signed and shall remain in effect until revoked by me in writing. I agree that the bank's rights, with respect to each debit, shall be the same as if it were drawn and signed by me. I further agree that, should any debit be dishonored, whether with or without cause, the bank shall be under no liability whatsoever, even though such dishonor results in the termination of insurance. SIGNATURE OF DEPOSITOR X DATE */ * / *   Home  | What is CHAMPVA  | How it Works  | Supplement Application  | Contact Us | Login All rights Reserved by Champvaus.com