Group TRICARE Supplement Insurance Plan Online Enrollment Form

Policy # AGP-5859/AGP-5860

Section 1: Basic Information

Your personal information is protected. We will not share or sell your information.

Coverage Status
Basic Information
mm/dd/yyyy
Why do we ask for this? We need your Social Security Number to make sure our records are complete and accurate. Your privacy is important to us, and we don’t share this information with anyone else. ###-##-####
Current Mailing Address
will autofill city/state
Permanent Address
will autofill city/state
Contact Information
###-###-####
###-###-####
Military Status
mm/dd/yyyy
Service Information

Section 2: Coverage

Coverage
Additional Information

Are you enrolling within 60 days of termination of Active Duty Service?

Are you enrolling within 30 days of the date your employer health insurance ends because you are no longer an eligible participant in that program?

Have you enrolled in the TRICARE Reserves Select within the past 30 days?

Section 3: Dependents

If you are applying for coverage for your Children, please provide the information requested below.

Child(ren)

Section 4: Payment Information

Payment Information

Based on your previous answers, your MONTHLY premium will be $0.00

will autofill city/state
First 9 digits from the lower left corner of your personal check
$

I hereby authorize Military Benefit Association to initiate on or after the second day of each month debit entries to my checking account indicated below and on the attached voided check, and I hereby authorize the depository institute named below to debit the same from my account. Said debits shall be for the amount(s) of my monthly premium payments at the regular rates applicable to these premiums. It is understood that the amounts of these debits will be adjusted by MBA in accordance with any applicable premium increases or decreases.

My premium is due and payable on the first of each month. I agree that if any such debit is dishonored, whether with or without cause and whether intentionally or unintentionally, MBA and the depository institution shall be under no liability whatsoever even if termination of insurance results. This agreement is to remain in full force and effect until MBA has terminated it upon 60 days notice to me, or received notification from me of its termination in such time and manner as to afford MBA a reasonable opportunity to act on it.

Speak to an agent: 1 877-622-1020 Existing members call: 1 800-336-0100