Dear AFA Member,

Thank you for requesting more information about the Air Force Association’s TRICARE Reserve Select(TRS) Supplement Insurance Plan, underwritten by Hartford Life and Accident Insurance Company.

Enclosed you will find everything you need to make a decision for you and your family.

As you may already know, your out-of-pocket medical expenses may add up quickly, especially when you receive care outside of the military health system.

That’s why supplemental health insurance like the TRICARE Reserve Select Supplement Plan may be so important for you and your family.

With this insurance coverage, you and your family may be better protected against the high cost of medical expenses you might face each year in the event of an illness or injury.

Plus, this plan includes these features:

• May help pay your TRICARE Reserve Select cost-shares for covered inpatient and outpatient care.

• Pays 100% of covered expenses in excess of the TRICARE-allowed amount, not to exceed the legalllimit.

• Covers your eligible spouse and dependent children.

• You qualify for competitive group rates thanks your AFA membership.

Please review the enclosed Benefits Summary for your rates and other important details about this plan. Then to enroll, complete and return the enclosed Enrollment Form. Send no money now.

Once your form is received, we will send you a Certificate of Insurance. You’ll have 30 days to look over the plan benefits. If you decide to continue with this coverage, pay the bill accompanying your Certificate. If you decide it’s not what you had in mind, simply let us know. You’re under no obligation.

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Here’s the TRICARE Reserve Select Supplement Insurance Plan information you requested.

Information Request For AFA Member:

Coverage is available for your TRICARE eligible spouse under age 65, and dependent, unmarried children under age 21(23 if a full-time college student).

Thank you again for considering this valuable plan. We look forward to your participation.

Sincerely, Sincerely,

Erika SalessesManager, Business Development Air Force Association

Anthony A. Baldus, PrincipalMercer Health & Benefits Administration LLC AFA Insurance Plans Administrator License #8704140

P.S. As an eligible TRICARE Reserve Select member of the Air Force Association, you have a guaranteed right tothis supplemental plan. And it’s easy to enroll today. Just complete and return the enclosed Enrollment Form.

Underwritten by:Hartford Life and Accident Insurance Company, Hartford, CT 06155

TRICARE Form Series includes Form GBD-3000 (2017); Form GBD-3100 (2017) or state equivalent.

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TCRS-AFA-LTR 111TRSL-AFA

Name:Last First MI

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City, St., Zip:

Air Force Association

TRICARE Reserve Select Supplement Insurance PlanEnrollment Form To Enroll:

Send this completed form to:ADMINISTRATORAFA GROUP INSURANCE PROGRAMP.O. Box 14464Des Moines, IA 50306-8993

QUESTIONS?Call : 1-800-291-8480 E-Mail: afa.service@mercer.com

Underwritten by:Hartford Life and Accident Insurance Company One Hartford PlazaHartford, CT 06155

1. COMPLETE PERSONAL INFORMATION.

Phone Numbers

Date of BirthHome ( )

(Mo./Day/Yr.)Work ( )

E-Mail Address

Social Security Number

Membership Number

Date of Retirement ___________________________ (Mo./Day/Yr.)

Names of Family Members Enrolling Date of Birth(Mo./Day/Yr.)

SpouseChildren*Children*Children*

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Group A: 1117105TR-Q If Initial Service date is prior to 1/1/2018 Group B: 1118105TR-Q If Initial Service date is after to 1/1/2018 Young Adult coverage: 1118105TR-Q

074030010144

(For administrator use: 11171 if date is prior to 1/1/2018, otherwise 11181. All TRICARE Young Adult coverage will be 11181.)

Member (TS21)

Child(ren) Each Child (under age 21 [23 if a full-time student]) (TS27)

*Children up to age 21 (or 23 if full-time student or 26 if covered under TRICARE Young Adult) qualify.

Each Child (age 21-25 [if enrolled in TRICARE Young Adult]) (11181-TC17)

2. SELECT COVERAGE.

If you're Active Duty military status, only spouse and children coverage is available. Please complete the information below. Please list additional dependents on a separate sheet, sign and date.

Spouse (TS25)

Sex M F

Initial Service Entry Date(Mo./Day/Yr.)

3. SIGN AND DATE:I acknowledge that I have been given the opportunity to enroll in the AFA TRICARE Reserve Select Supplement Insurance Plan and that I am age 64 or younger, unless ineligible for Medicare, an AFA member and that the above information is true and complete to the best of my knowledge.

I understand that this program may not cover pre‑existing conditions (conditions for which I received medical advice ortreatment within 6 months prior to the effective date of coverage or until the coverage has been in effect for 6 months).This pre-existing condition limitation will not apply if waived in accordance with policy provisions.

I understand that my coverage will become effective on the first day of the month following receipt of my completedEnrollment Form and payment of my initial premium.

I understand that eligibility to receive benefits under this TRICARE Retiree Supplement is dependent on my (or my deceased spouse’s) entitlement to uniformed services retired pay.

I understand and agree that insurance will go into effect upon receipt of my first premium payment and this Enrollment Form and remain in effect only in accordance with the provisions, terms and conditions of the insurance policy. I understand and agree that only the insurance policy issued to my Association can fully describe the provisions, terms, conditions, limitations and exclusions of my insurance.

Member’s Signature X ______________________________________________ Date X _______________

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companyHartford Life and Accident Insurance Company.

TRICARE Form Series includes Form GBD-3000 (2017); Form GBD-3100 (2017) or state equivalent.

Master Policy #AGP-5924

111TRSE- AFA

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(Mo./Day/Yr.)

TCRS-AFA-ENR

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Stock: 660005

AUTOMATIC CHECK WITHDRAWAL REQUEST: By selecting Automatic Check Withdrawal, your premium willautomatically be withdrawn from your checking account. Please provide the information requested below.

Routing #: ____ ____ ____ ____ ____ ____ ____ ____ ____ Account #:_________________________________

I request that you pay and charge my account debits drawn from my account by the Plan Administrator to its order. Thisauthorization will stay in effect until I revoke it in writing. Until you receive such notice, I agree that you shall be fullyprotected in honoring any such debits. I also agree that you may, at any time, end this agreement by giving 30 daysadvanced written notice to me and to the Plan Administrator. You are to treat such debit as if it were signed by me. If youdishonor such debit with or without cause, I will not hold you liable even if it results in loss of my insurance.

Signature of Premium Payer______________________________________________ Date_____________________

Stock: 660005

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Stock: 660005

TRICARE Reserve Select Supplement Insurance PlanBenefits Summary

1Guaranteed IssueYou are guaranteed issue provided you are a member of the Select Reserve or the Ready Reserve andenrolled in TRICARE Reserve Select (TRS) and under age 65. You cannot be eligible for or enrolled in the Federal Employees Health Benefits Program (FEHBP) or currently covered under FEHBP (either under your own eligibility or through a family member with FEHBP).1 See Pre-Existing Conditions Limitations on the next page.

Coverage is also available for your TRS eligible spouse under age 65, and dependent, unmarried children under age 21 (23 if a full-time college student). Coverage is extended to adult dependent children who are under age 26 and enrolled in the TRICARE Young Adult (TYA) program. You, the member, must be enrolled in order for spouse/dependent children to enroll.This policy is guaranteed issue but does contain a Pre-Existing Condition Limitation. Please refer to the section titled Pre-Existing Conditions Limitation for more information on exclusions and limitations, such as Pre-Existing Conditions.

Helps Pay Expenses TRICARE Doesn’tTRICARE Reserve Select (TRS) provides excellent health care coverage. However, it was never designed to cover all expenses.This TRS Supplement Insurance Plan works with TRICARE tohelp pay expenses TRICARE doesn’t cover.

Specifically, once you meet any TRICARE deductibles, it pays:

• 100% of your cost-shares for doctor visits, hospitalstays, surgeries and more.

• Pays 100% of your prescription drug copays.• Pays 100% of the difference between what your doctor bills

you and the amount TRICARE allows (excess charges).

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Competitive Group RatesAs a member, you benefit from your Air Force Association membership. The result: these group rates to fit yourbudget. (Note: MONTHLY rates shown below.)

Under Age 65Member: $8.24Spouse: $8.24Each Child:* $7.21

It’s easy to enrollJust complete the enclosed Enrollment Form — making sure to provide all

information requested — and return it. Send no money now.After your completed Enrollment Form is received,

you’ll be sent a certificate of insurance, which you can examine for 30 days, risk-free.

Rates and/or benefits may be changed on a class basis. Rates are based on the attained age of the Insured personand increase as you enter each new age category.NOTE: You will be billed quarterly. To calculate premiums quarterly, semi-annually or annually, just multiply yourmonthly premium by 3, 6 or 12 respectively.

*Newborn children not named in your enrollment form are automatically covered from birth for injury or sickness,including treatment of congenital defects and birth abnormalities, for 31 days. You must notify the Plan Administratorin writing and pay the additional premium due within 31 days of birth for coverage to continue beyond this period.Insured children who are incapable of self-sustaining employment because of mental incapacitation or physicaldisability, and who are unmarried and chiefly dependent on the insured member for support and maintenance—maycontinue coverage past policy age limits, with requested proof. Otherwise, each dependent child's coverageterminates on the premium due date following the date he or she is no longer a dependent.

(Please note, there are NO deductibles with this TRS Supplement Insurance Plan.)

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Effective DateYour coverage and that of your covered dependentsbecomes effective on the first day of the monthfollowing receipt of your Enrollment Form and firstpremium payment. If, on that day, you or a covereddependent are confined in a hospital, the effectivedate will be the day following discharge from thehospital.

1Pre-Existing Conditions LimitationsAny injury or sickness whether diagnosed orundiagnosed, for which a covered person receivedmedical care or treatment within the 6 month periodpreceding the effective date of his or her insurance willnot be covered until the coverage has been in effectfor 6 months. However, new conditions will be coveredimmediately.

ExclusionsThe Policy does not cover:1. injury or sickness resulting from war or act of war,whether war is declared or undeclared; 2. intentionallyself-inflicted injury; 3. suicide or attempted suicide,whether sane or insane. The Policy limits coverage for:1) routine physical exams and immunizations, exceptwhen: a. rendered to a child up to 6 years from thechild’s birth; or b. ordered by a Uniformed Service:i. for a Covered Dependent of an Active Duty Member;ii. for such Dependent’s travel out of the United Statesdue to your assignment; or c. required for schoolenrollment (but not sports physicals) by a CoveredChild aged 6 through 11; 2) domiciliary or custodialcare; 3) eye refractions and routine eye exams exceptwhen rendered to a child up to 6 years from the child’sbirth; 4) eyeglasses and contact lenses; 5) prostheticdevices, except those covered by TRICARE;6) cosmetic procedures, except those resulting fromSickness or Injury, while a Covered Person; 7) hearingaids; 8) orthopedic footwear; 9) care for the mentally orphysically incapacitated if: a. the care is requiredbecause of the mental or physical incapacitation;b. or the care is received by an Active Duty Member’schild who is covered by the TRICARE Extended CareHealth Option (ECHO); 10) drugs which do not requirea prescription, except insulin; 11) dental care unlesssuch care is covered by TRICARE, and then only tothe extent that TRICARE covers such care; 12) anyconfinement, service, or supply that is not coveredunder TRICARE; 13) Hospital nursery charges for awell newborn, except as specifically provided underTRICARE; 14) any routine newborn care except WellBaby Care; 15) any expense or portion thereof which isin excess of the Legal Limit;16) expenses in excess ofthe TRICARE Catastrophic Cap; 17) that part of anyCovered Expense which is in excess of the TRICAREAllowed Amount, except as otherwise stated in theplan benefits;

Member TerminationYour coverage under the Policy will cease on the first tooccur of:1. the date the Policy terminates; 2. the date the requiredpremium is not paid, subject to the Grace Period provision; 3. the first day of the month on or next following the date you cease to be a member of the Policyholder; 4. the first day of the month on or next following the date you cease to be eligible for the Plan under which you are covered; 5. the date The Hartford or the Policyholder cancel coverage for a Class of Eligible Person to which you belong; 6. the date you attain age 65; 7. the date you cease to be covered under TRICARE; 8. the date you become eligible for Medicare unless youreside in an area where Medicare is not available, in which case coverage will not terminate until you return to residency in an area where Medicare is available.

Termination of coverage will be without prejudice to anyclaim which originated before the effective date oftermination.

DefinitionsConfined or Confinement means being an Inpatient in a Hospital (or Skilled Nursing Facility) due to Sickness or Injury. Skilled Nursing Facility means one which:(a) is approved by Medicare or is qualified to receive approval by Medicare if so required; (b) operates pursuant to law; (c) primarily and continuously provides skillednursing care and related services to persons convalescing from Sickness or Injury on an Inpatient basis for which a charge is made; (d) provides 24-hour-a-day nursing service by or under the supervision of registered nurses (R.N.);(e) provides adequate procedures for the administration of drugs; (f) maintains daily medical records of each patient; and (g) provides each patient with a planned program of medical care and treatment by or under thesupervision of a Physician.

18) expenses which are paid in full by TRICARE;19) any expense or portion thereof applied to theTRICARE Outpatient Deductible; 20) treatment for theprevention or cure of alcoholism or drug addiction, exceptas specifically provided under TRICARE and The Policy;21) nursing services, unless it is for the nurse’s full-timeservice while the Covered Person is an Inpatient in aHospital; 22) any part of a Covered Expense which theCovered Person is not legally obligated to pay because ofpayment by a TRICARE alternative program; any claimunder more than one of the TRICARE Supplement Plans.If a claim is payable under more than one plan or benefit,payment will only be made under the provision thatprovides the highest coverage.

Non-Duplication of Coverage under EmployerHealth ProgramIf a claim payable under the Policy is also payable under an Employer Health Program with TRICARE as the secondary payor, The Hartford will limit our payment to an amount which, when added to the amounts paid by the Employer Health Program and TRICARE, will not exceed 100% of TRICARE Covered Expenses.

Change of Policy PremiumsThe Hartford has the right on each Premium Due Date to change the rate at which premiums will be calculated. This includes the right to change premium rates for a benefit that applies to all individuals of the same class, age, plan and effective date. Rates may be changed based on claims experience of the Policy. The Hartford will give the Policyholder or Organization notice of any change at least 45 days before the Premium Due Date on which it is to become effective.

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This is a supplemental health insurance plan that requires you to have major medical coverage, Medicare, or other health coverage that meets “minimum essential coverage” as defined by the Affordable Care Act.

This coverage is available only for residents of the United States excluding AK, ME, NM and UT.

Dependent TerminationThe dependent’s coverage under the Policy will cease on the first to occur of:(1) the date this Policy terminates; (2) the date the required premium is not paid, subject to the Grace Period provision;(3) the first day of the month on or next following the date the dependent ceases to be an Eligible Spouse or an Eligible Child; (4) the first day of the month on or next following the date the dependent ceases to be eligible for the Plan under which the dependent is covered; (5) the date The Hartford or the Policyholder cancel coverage for a Class of Eligible Person to which the dependent belongs; (6) the date the Member ceases to be covered, subject to the Covered Dependent Continuation provision (this will not apply to the Spouse or Child of an Active Duty Member or a Service Disabled Member); (7) the date the dependent becomes eligible for Medicare unless the dependent resides in an area where Medicare is not available, in which case coverage will not terminate until the dependent returns to residency in an area where Medicare is available; (8) if a child, the date the child attains age 21 or age 23 if the child is enrolled full time at a school of higher learning; (9) the date a dependent ceases to be covered under TRICARE; (10) the date a dependent attains age 65.

Termination of coverage will be without prejudice to any claimwhich originated before the effective date of termination.

It’s easy to enrollJust complete the enclosed Enrollment Form — making sure to provide

all information requested — and return it. Send no money now.After your completed Enrollment Form is received,

you’ll be sent a certificate of insurance, which you can examine for 30 days,risk-free.

QUESTIONS? Call: 1-800-291-8480 E-Mail: afa.service@mercer.com

Web: afainsure.com

Mercer Consumer, a service of Mercer Health & Benefits Administration LLCP.O. Box 14464Des Moines, IA 50306-8993

AR Insurance License #100102691CA Insurance License #0G39709In CA d/b/a Mercer Health & Benefits Insurance Services LLC

Underwritten by:

Hartford Life and Accident Insurance CompanyHartford, CT 06155

Administered by:

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing company of Hartford Life and Accident Insurance Company.

This fact sheet explains the general purpose of the insurancedescribed, but in no way changes or affects the policies asactually issued. In the event of a discrepancy between thisfact sheet and the policy, the terms of the policy apply. Allbenefits are subject to the terms and conditions of the policy.Policies underwritten by Hartford Life and Accident InsuranceCompany detail exclusions, limitations, reduction of benefitsand terms under which the policies may be continued in fullor discontinued. Complete details are in the Certificate ofInsurance issued to each insured individual and the MasterPolicy issued to the policyholder. This program may not beavailable to residents of all states.

TRICARE Form Series includes Form GBD-3000 (2017); Form GBD-3100 (2017) or state equivalent.

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