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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
*
/
*
/
*
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