EASY SUPPLEMENT ENROLLEMENT - Select the Supplement That is Right for You



TRICARE SUPPLEMENTAL INSURANCE (Extra/Standard)

  1. Print your name and address clearly on the TRICARE Supplement Enrollment Form
  2. Sign and Date Enrollment Form where indicated
  3. Check appropriate boxes to indicate coverage you have chosen
  4. Calculate your premium from the schedule
  5. Complete CHECK-O-MATIC FORM with correct premium
  6. Make Check payable according to attached instructions and application.

TRICARE RESERVE SELECT SUPPLEMENTAL INSURANCE

  1. Print your name and address clearly on the Reserve Select Supplement Enrollment Form
  2. Sign and Date Enrollment Form where indicated
  3. Check appropriate boxes to indicate coverage you have chosen
  4. Calculate your premium from the schedule
  5. Complete CHECK-O-MATIC FORM with correct premium
  6. Make Check payable according to attached instructions and application.

CHAMPVA SUPPLEMENTAL INSURANCE

  1. Print your name and address clearly on the CHAMPVA Supplement Enrollment Form
  2. Sign and Date Enrollment Form where indicated
  3. Check appropriate boxes to indicate coverage you have chosen
  4. Calculate your premium from the schedule
  5. Complete CHECK-O-MATIC FORM with correct premium
  6. Make Check payable according to attached instructions and application.m
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