06741/06742/1018/52247
Pleaseprintininkortype.Donotusecorrectionfluidorgelpens.Initialanddateanychanges.
TOAPPLY:
Sendthiscompletedapplication withyourpremiumcheckpayableto:
ANSGROUPINSURANCEPROGRAM
P.O.BOX10374
DesMoines,IA50306-8812
QUESTIONS?
Call:1-800-424-9883
AreyounowamemberofAmerican NuclearSociety?
G Yes G No Membership#__________
Transamerica Premier Life
Insurance Company
4333EdgewoodRoadN.E.
CedarRapids,IA52499
CANCER INSURANCE PLANAPPLICATION
FORRESIDENTSOFAL, AZ,DC,GA,HI, IAand OH
Yes.Enroll me in the cancer care plan.
Member:
Last First MI
Add1:
Add2:
City,St.,Zip:
Member'sDateofBirth / / Gender GMale GFemale PHONENUMBERS:
Home ( )
Work ( )
Fax ( )
1.Select your coverage:
Checkonebox:
Semiannual Premiums*
Member G$41.70
FamilyCoverage G$78.00
2.If, in addition to yourself, you are applying for familycoverage, complete below as applicable.
DATEOFBIRTH GENDER
DependentName
GMale GFemale
(nameifproposedforinsurance)
DependentName
GMale GFemale
(nameifproposedforinsurance)
CA187E7STATES # %&$"&$
1
*01050301000* To thebestofyourknowledgeandbelief,haveyouoryourdependents(ifapplying fordependentcoverage)everreceived
treatment orbeenmedicallyadvisedofCancer(excludingSkinCancer),LeukemiaorHodgkin'sDisease duringthelast5years,
2yearsinGA? GYes GNo
(Treatmentmeansmedicalandsurgicalcareby alicensedprovidertodetectorcureCancer.Thisincludesexamination,
diagnostic procedures,surgery(including pre-andpost-operativecare),prescribedmedicationandtheapplication ofremedies
andtherapy.Itdoesnotincludeanydiagnostic proceduresorexaminations performedtomonitorapreviousremovalor remedy
ofCancer,provided thereisnopositivediagnosisofCancer orofarecurrenceofCancer.)
Ifyouanswered"Yes," pleaseindicatethename(s)oftheperson(s)andtheircorresponding medicalcondition(s).
Itis understoodthat anypersonlistedabovewill notbeeligibleforcoverageexceptany personlistedwith SkinCancer.Any
person listedwith SkinCancer willbe eligibleforcoverage.Benefits, however,willnot bepayableforSkinCancerduringthe
first12monthsofcoverage.Itisunderstoodthatno benefitswill bepayableforexpensesincurredduringthe first12 months
ofcoverageforanycancerdiagnosedor treatedwithin thefirst30daysafter theinsuredperson's effectivedateofcoverage
(not applicabletoresidentsofAZ).
Yourcoveragewillbe effectiveonthefirstdayofthemonth followingacceptanceofyourapplication, providedyourfirst
premiumis paidandyouarenothospital-confinedonthat date.
Are youorany dependentseligiblefor Medicare? ___Yes ___No
Noticeto Consumer:
THISISA SUPPLEMENTTOHEALTHINSURANCEANDISNOTA SUBSTITUTEFORMAJORMEDICALCOVERAGE.LACK OF
MAJORMEDICALCOVERAGE(OR OTHERMINIMUMESSENTIALCOVERAGE)MAYRESULT INANADDITIONALPAYMENT
WITH YOURTAXES.ALSO,THE BENEFITSPROVIDEDBYTHISPOLICYCANNOT BECOORDINATEDWITHTHEBENEFITS
PROVIDEDBYOTHERCOVERAGE.PLEASEREVIEWTHE BENEFITSPROVIDEDBYTHISPOLICYCAREFULLYTOAVOIDA
DUPLICATION OFCOVERAGE.
NOTICE: Thispolicymayonly beissuedifyouhaveminimumessentialcoveragewithinthe meaningofsection5000A(f) ofthe
InternalRevenueCode, oryouaretreatedashavingminimumessentialcoverageduetoyourstatusasabonafideresidentof
any possessionoftheUnitedStatespursuanttoCodesection5000A(f)(4)(B). Ifyouhaveemployer-sponsored coverage,
COBRA coverage,insurancepurchasedfromDCHealthLink,Medicare,or othersimilarinsurance,youlikelyhaveminimum
essential coverage.Ifyourminimumessentialcoverageisterminatedforanyreason,youshould notifythecompany
immediately.
Questions (1),(2),and(3)belowarenotrequiredforapplicantsage65orolder.
(1)Doyouhavecomprehensivemedicalcoverageincludingthe minimumessentialcoveragerequiredbytheAffordable Care
Act(ACA)orare youtreatedashavingminimumessential coverageduetoyourstatusasabonafideresidentofany
possessionoftheUnitedStates? G Yes G No
If youansweredNO toquestion 1,youarenot eligiblefor thispolicy,intheformofhospitalorfixedindemnity insurance.
(2)Doyouunderstandmostsupplementalonly policiesmaynotpay fullbenefitsif yourACA compliantminimumessential
coverageplanis notinforce? G Yes G No
(3)Doyouunderstandthatthe benefitsprovided underthispolicymaybe limited? G Yes G No
Signature ofApplicant : Date :
Signature ofSpouse : Date :
(ifapplying)
DC andOHResidents:Anypersonwhoknowinglyandwithintenttoinjure,defraudordeceiveanyinsurerfiles astatement of
claimoran applicationcontainingany false,incompleteormisleading informationisguiltyofacrimeandmaybe subjectto
fines orconfinement inprison.
CA4000GAMR1015
July2017
*If applicable,an additional$2 billingfeewillbe includedon yourbillingnoticepayabletothe administrator.Tosavethefee,
selectElectronicFundsTransfer(EFT)asasafeandsecurepaymentoption.
MZ080057710A
CA187E7STATES # %&$"&$
CA187P # %&$"&$
For AmericanNuclearSocietyMembersandTheirFamilies
PROTECTINGYOURSELF
AccordingtotheCancerFactsandFigures2017,intheUS,
menhaveslightlylessthana1in2lifetimeriskofdeveloping
cancer;forwomen,theriskisalittlemorethan1in3.*
Fortunately,advancesincancertreatmentaresavingmore
livesthaneverbefore.Withtheseadvancesincare,however,
comerisinghealthcarecosts.Therecanbehospitalexpenses,
specialists'fees,prescriptiondrugs,operations,dayandnight
nursingcare,therapists...andmore.
Thisplanmayprovideyouwithcashbenefitstohelpcoverthe
costsofcancertreatmentandotherincidentalcosts.That
meansitpaysyoubenefitsforcoveredclaimsregardlessofany
othercoverageyouhave.
Withthisvaluableprotectionyoucancollectbenefitssix
differentways:
1. $9,000for"firstoccurrence"cancer(notpayableforskin
cancer)**
2. $100adayforhospitalization(days1through60)
3. $250adayforhospitalization(days61andover)
4. $100adayforoutpatienttreatment,including
chemotherapy
5. $120MaximumBenefitforWellnessCareBenefit
6. $100adayforhospicecare(maximum180days)
Whoiseligible?
YOU(themember)andyourSPOUSEareeligibleforthis
insurancecoverageifyouhavenotbeenmedicallydiagnosed
with,treatedfor,oradvisedofcancer(exceptskincancer)
withinthe5years(12monthsinTX,2yearsinGA)priortothe
effectivedateofyourcoverage.
YOURDEPENDENTCHILDRENarealsoeligibleforcoverage
iftheyareunderage19(underage25ifafull-timestudentin
anaccreditedcollege,university,vocationalortechnicalschool)
andhavenotbeenmedicallytreatedfor,oradvisedofcancer
(exceptskincancer)withinthe5yearspriortotheeffective
dateofyourcoverage.Pleasenote,dependenteligibilityages
varybystate.YourCertificate/Policywillprovidethefull
details.
*Thesestatisticshavebeenmadeavailableby"CancerFactsandFigures,2017."
**n/ainMN
Whatare thebenefits?
BENEFIT PAYMENTTOYOU DESCRIPTION
FirstOccurrence $9,000 Paidwhencancer(exceptskincancer)isfirstdiagnosed...paid
onceperlifetime...coveragemustbeinforce30dayspriorto
diagnosis.
ExtendedHospital
Confinement
Days1through60
$100perday Paidbeginningthefirstday.Benefitinlieuofallotherbenefits.
HospitalConfinement
Days61+
$250perday Paidbeginningthe61stdayduringanyillnessperiod.
WellnessCare $120MaximumBenefit Paidfor6screeningtests/exams,uptothe$120MaximumBenefit.
OutpatientTreatment $100perday Paidforoutpatienttreatmentincludingchemotherapy.
HospiceCare $100perday Paidwhenyourlifeexpectancyis6monthsorless...180days
lifetimemaximum.
CA187P # %&$"&$
*01060302000*
Youwillreceiveallthebenefitsforwhichyouareeligible
regardlessofwhatphysicianyouseeorwhathospitalyouuse.
TherearenorestrictionsaslongastheymeetthePlan
definitions.
Howarebenefitspaid?
Allbenefitcheckswillbesentdirectlytoyouortoanyoneyou
choose...nevertoyourdoctororhospitalunlessyou
specificallyrequestit.
Arebenefitspaidregardlessofanyothercoverage?
Therearenocoordinationofbenefitsorco-paymentswiththis
Plan.ThisisasupplementalPlanthatpaysregardlessofany
otherinsuranceyouhavewithothercompanies.
Howcanthebenefitsbeused?
Helptopaythemortgage...buyfood...paymedicalbills...
thechoiceisyours.Youcanuseyourbenefitsanywayyou
want.
Whenwillcoveragebecomeeffective?
Yourcoveragewillbecomeeffectiveonthedateshownon
yourCertificateofInsuranceprovidedyouhavepaidyourfirst
premium,andyou(oranydependentstobeinsured)arenot
hospital-confinedonthatdate.
What'sthecost?
TransamericaPremierLifeInsuranceCompanyhastheright
tochangeratesonanypremiumduedatewith31daysnotice
totheinsured.RatesmayalsochangeatanytimeiftheGroup
MasterPolicychanges.
ONERATEFORALLAGES
SEMIANNUALPREMIUMS
INDIVIDUALPLAN FAMILYPLAN
(youonly) (you,yourspouse
andyourchildren)
Standard
OptionPlan $41.70 $78.00
Ifapplicable,anadditional$2billingfeewillbeincludedonyour
billingnoticepayabletotheadministrator.Tosavethefee,
selectElectronicFundsTransfer(EFT)asasafeandsecure
paymentoption.
YourPaymentOptions
Pleasenote:Youalsomayhavetheoptionofpayingyour
premiumsonceayear(annually),twiceayear(semi-annually),
orfourtimesayear(quarterly).Ifyoupayyourpremiums
monthly,quarterlyorsemi-annually,thetotalamountof
premiumsand/oradministrationfeesthatyoupayinayear
maybehigherthanifyoumakeoneannualpayment.Ifyouare
interestedinlearningmoreaboutthesepaymentoptions,
pleaserefertoyourfulfillmentpackagefordetails.
Whatisn'tcovered?
Thisplanpaysbenefitsonlyfortreatmentresultingfromcancer,
andrecommendedandapprovedbyorperformedbya
physician.
Exclusions
BenefitswillnotbepaidunderthePolicyandanyattached
Riderforanyexpensesthatresultfrom:
1)injuryorsicknessotherthanCancer;
2)treatmentorservicesperformedoutsideoftheUnitedStates.
Pre-existingConditionLimitation
Acancerforwhichtreatmenthasbeenreceivedbeforethe
coveredpersonhasbeeninsuredfor30daysfromhiseffective
dateofcoveragewillbeconsideredapre-existingcondition
however,makepaymentsforthiscancerifthecoveredperson
incursexpensesafterhisorherinsurancehasbeenineffectfor
12months.
TerminationofCoverage.Coverageendsif:theMasterPolicy
isterminated;thememberisnolongeramemberofhis/her
association;ortheinsuredfailstopaytheappropriatepremium.
Dependent'scoverageendswhenmember'scoverageends,its
premiumsarenotpaid,theMasterPolicyisterminated,oron
thepremiumduedatecoincidingwithornextfollowingthedate
thedependentceasestobeeligible.
ThisCancerExpenseInsurancePlanisAdministeredBy:
MercerConsumer,aserviceofMercerHealth&
BenefitsAdministrationLLC P.O.Box10374 DesMoines,IA50306-8812 QUESTIONS? 1-800-424-9883 http://www.insurancetrustsite.com/ans ARInsuranceLicense#100102691 CAInsuranceLicense#0G39709
InCAd/b/a MercerHealth&Benefits
InsuranceServicesLLC
ThisCancerExpenseInsurancePlanisUnderwrittenBy:
4333EdgewoodRoadN.E.
CedarRapids,IA52499
Otherinsuranceinthiscompany:Onlyonecertificateorpolicy
providingCancercoveragemaybeinforceaselectedbythe
member.Ifanyothercertificateorpoliciespreviouslyissued
byusoranyotherAEGON,U.S.A.affiliatesareinforce
concurrentlywiththeCertificateissuedunderthispolicy,the
excessinsurancewillbevoid.Allpremiumspaidfortheexcess
willbereturnedtotheInsured.
Thisbrochurecontainsabriefdescriptionoftheprincipal
provisionsandfeaturesofthePlan.Thecompletetermsand
conditions,includinglimitationsandexclusions,aresetforth
intheGroupPolicyMZ080057710A.
CA1000GPM,CA1000GCM.series
THISISACANCERONLYPOLICY
30-DayFreeLookPeriod
AfteryoureceiveyourCertificateofInsurance,youcantake
upto30daystoreviewit.Ifyoudecideyoudon'twant...or
need...thisvaluablecoverage,simplyreturnyourCertificate
within30daysofreceipt.Yourcoveragewillbevoidfromits
inceptionandanypremiumsyouhavepaidwillberefundedto
youinfull.You'llhavenoobligationwhatsoever.
ANoticeAboutTransamerica'sPrivacyPolicy
Pleasevisit:
https://www.transamerica.com/individual/privacy-policy/
NOTAVAILABLEINALLSTATES
Copyright2017MercerLLC.Allrightsreserved.
July2017