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Texas Farm Bureau Rural Health Association Wants To Help You Get the Most Out of Your Medicare Benefits

Dear Member: Because you're a valued Texas Farm Bureau member, we're pleased to make this information on Texas Farm Bureau Rural Health Association - Endorsed Medicare Supplement Insurance Plans available to you. Enclosed are the Medicare Supplement insurance plans sponsored* by the Texas Farm Bureau Rural Health Association. They are underwritten by Transamerica Life Insurance Company (Transamerica Life), Cedar Rapids, IA.

Why consider Texas Farm Bureau Rural Health Association sponsored plans? Today, Medicare Supplement insurers can only offer standardized policies. With this benefit uniformity in mind, we think your decision on who to buy your coverage from should be based on the following criteria: • Value - Does the insurance plan offer you a solid value for your insurance dollar? Compare

Transamerica Life annual premiums to those of other plans and see for yourself. • Reliability - Does the insurance company have the kind of financial strength and track record you can

rely on? We have selected Transamerica Life Insurance Company as the underwriter of our program because of their financial strength and reliability.**

• Service - Does the administrator provide the kind of prompt and courteous service you should expect and can count on? Whether you are making a claim for benefits or simply have a question, we think you will be impressed with the service behind the plan.

But which of the insurance plans is right for me? There is no single best choice. The insurance plan that is best for you is the one that most closely meets your specific personal needs. We recommend you especially consider: Plans A, F and N. Each insurance plan provides a different level of protection - so you can compare them and fit them to your personal needs and budget. Benefits do not exceed any charge limitation established by the Medicare program or state law. To help you make an informed choice, detailed charts are included in the outline of coverage showing all the benefits provided. THE OUTLINE OF COVERAGE CONTAINS IMPORTANT INFORMATION. IT PROVIDES A BRIEF DESCRIPTION OF SOME OF THE IMPORTANT FEATURES OF THE POLICY. PLEASE REVIEW THE ACCOMPANYING OUTLINE OF COVERAGE FOR EACH POLICY FOR WHICH YOU MAY WANT TO APPLY. One of our recommended insurance plans may be the right one for you. However, if you would like detailed information about any of the plans, simply call us at 1-800-999-8932.

Are you nearing Medicare enrollment? Make sure you take advantage of your Open Enrollment Period. Your one-time Open Enrollment Period begins the date you are enrolled in Medicare Part B and are age 65 or older. This period lasts for 6 months. During this time, you can buy any Medicare Supplement Insurance plan you choose regardless of any health problems. The insurance company cannot deny you coverage or charge you more than other applicants for the certificate. If you are under age 65, have Part A and have enrolled in Part B within six months you also have an open enrollment period. And if you have previously been enrolled in Medicare, Parts A and B, you have an open enrollment period when you turn 65.

* Paid Endorsement ** Transamerica Life Insurance Company, is rated "A+" (2nd out of 16) by the A. M. Best Company for Financial Strength and operating performance, "AA-" (4th of 21

Categories) by Standard & Poor's for claims paying ability. Ratings are current as of June 24, 2016 and May 12, 2015 respectively.

TX FARM MIPPA LETTER2017 Ad Trac 1376101

What if I already have other coverage? Compare your current coverage to these insurance plans. You may be surprised to find that these plans offer you a better value than the plan you now have. Plus, if you replace a Medicare Supplement or primary hospital and medical expense reimbursement coverage you have had for six or more months with one of these plans, you will not be subject to any pre-existing conditions limitations. Pre-existing conditions limitations are waived if the Medicare Supplement plan replaces creditable coverage within 63 days. (Pre-existing conditions include any sickness or injury for which you were treated or advised by a physician during the six months prior to the effective date of your new coverage.) This means you can switch without any waiting periods for benefits - regardless of your health or which of the insurance plans you select! Outside of an open enrollment or guaranteed issue period, pre-existing condition limitations would apply.

Issue Age Advantage Your Texas Farm Bureau Medicare Supplement is an issue age policy. You keep your initial premium at the age you first enroll. Your rate does not increase every year at your birthday. You will only get an increase in premium when there are state approved rate changes for all of the group certificates. Over time this may be a great advantage for savings and stability.

Are there other features I should look for? When you select a Medicare Supplement group insurance plan, underwritten by Transamerica Life, you will have:

• Lifetime protection - You cannot be canceled or refused future protection as long as you pay your premium when due.

• A 30-day right to examine your Certificate - Once you receive your Certificate of Insurance, take up to 30 days to review it. If not completely satisfied, return it for a full refund - no questions asked!

How do I apply? To apply for one of the Medicare Supplement insurance plans, underwritten by Transamerica Life, follow these simple steps: choose the Medicare Supplement insurance plan that best fits your needs, complete and sign the enclosed application, making sure you indicate your plan choice and whether you also want coverage for your spouse, and mail your application, along with a check for the first monthly premium, in the envelope provided. Discover for yourself the security and value of being covered by a Transamerica Life Medicare Supplement insurance plan. Take advantage of this important opportunity by completing the enclosed application and returning it today, or contact your local agent or Texas Farm Bureau. Sincerely,

Laurie A. Renko Vice President Transamerica Life Insurance Company

P. S. Texas Farm Bureau Rural Health Association - Endorsed Medicare Supplement insurance program, underwritten by Transamerica Life, is committed to providing the highest possible quality in protection and service. If you have any questions, or need any assistance in any way, please call toll-free at 1-800-999-8932, Monday through Friday, 8:00 a.m. to 5:00 p.m., Central Time.

Benefits are provided under Policy Form #: MS8500GPT.TXFB, Certificate Form #: MS8500GCT.TXFB-A. MS8500GCT.TXFB-F and MS8500GCT.TXFB-N. This Medicare Supplement Insurance plan is not connected with or endorsed by the US Government or Federal Medicare Program.

Exclusions & Limitations – Benefits for any expenses which are not determined to be Medicare Eligible Expenses by the Federal Medicare Program or its administrators will not be paid except as otherwise specified in the policy.

This is a solicitation for insurance. Your response may generate communication by a licensed agent. You cannot obtain coverage under this insurance policy until you complete an application for coverage. You should not send money to the issuer of the health insurance plan in response to this advertisement.

Issued Age Plan A Plan F Plan NUnder 65 $355.31 ** **

65 $123.35 $177.33 $131.6266 $126.20 $181.43 $134.6667 $129.05 $185.53 $137.7068 $131.90 $189.63 $140.7469 $134.75 $193.73 $143.7970 $137.61 $197.83 $146.8371 $140.46 $201.93 $149.8772 $143.31 $206.03 $152.9273 $146.16 $210.13 $155.9674 $149.01 $214.23 $159.0075 $152.58 $219.35 $162.8176 $155.43 $223.45 $165.8577 $159.00 $228.58 $169.6578 $162.56 $233.70 $173.4679 $166.13 $238.83 $177.2680 $169.69 $243.95 $181.0781 $172.54 $248.05 $184.1182 $175.39 $252.15 $187.1583 $178.25 $256.25 $190.2084 $180.39 $259.33 $192.48

85+ $180.39 $259.33 $192.48* Paid Endorsement TX** Plans available only to those age 65 and over.

TX Farm MIPPA Rate Sheet 2017 AT # 1376101

This Medicare Supplement insurance plan is not connected with or endorsed by the United States government of the Federal Medicare program.

To calculate rates other than Monthly multiply the monthly rate by: 3.080 for Quarterly, 6.050 for Semi-Annual, 11.630 for Annual

Rates are the same regardless of gender or tobacco use.Rates effective April 1, 2017

Benefits are provided under Policy Form #: MS8500GPT.TXFB, Certificate Form #: Plan A:MS8500GCT.TXFB-A, Plan F: MS8500GCT.TXFB-F and Plan N: MS8500GCT.TXFB-N

Texas Farm Bureau Rural Health Association*Medicare Supplement Plans – Monthly Issue Age Rates

Underwritten by Transamerica Life Insurance Company, Cedar Rapids, IA

Annual Issue Age Rates

Issue Plans Age A F N

Under 65

4,131.45

NA

NA

65 66 67

1,434.26 1,467.42 1,500.59

2,061.92 2,109.59 2,157.27

1,530.41 1,565.80 1,601.18

68 69

1,533.75 1,566.91

2,204.94 2,252.62

1,636.57 1,671.95

70 71 72 73 74

1,600.07 1,633.23 1,666.40 1,699.56 1,732.72

2,300.29 2,347.97 2,395.64 2,443.31 2,490.99

1,707.34 1,742.73 1,778.11 1,813.50 1,848.88

75 76 77 78 79

1,774.17 1,807.34 1,848.79 1,890.24 1,931.69

2,550.58 2,598.26 2,657.85 2,717.44 2,773.03

1,893.11 1,928.50 1,972.73 2,016.96 2,061.19

80 81 82 83 84 85+

1,973.15 2,006.31 2,039.47 2,072.63 2,097.50 2,097.50

2,836.63 2,884.30 2,931.98 2,979.65 3,015.41 3,015.41

2,105.42 2,140.81 2,176.20 2,211.58 2,238.12 2,238.12

Transamerica Life Insurance Company Benefit Chart of Medicare Supplement Plans Sold on or After June 1, 2010

Offering Benefit Plans A, F, and N These charts show the benefits included in each of the standard Medicare Supplement plans. Every company must make available Plan "A". Some plans may not be available in your state.

Basic Benefits: Hospitalization: Part A coinsurance plus coverage for 365 additional days, during your lifetime after Medicare benefits end. Medical Expenses: Part Bcoinsurance (generally 20% of Medicare-approved expenses) or co-payments for hospital outpatient

services. Plans K, L and N require insured to pay a portion of part B coinsurance or copayments.

Blood: First three pints of blood each year. Hospice: Part A coinsurance

Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan

A B C D F or F* G K L M N Basic,

including 100%PartB coinsurance

Basic, including 100%PartB coinsurance



Basic, including

100%PartB coinsurance*


Hospitalization and preventive care paid at 100%;other basic benefits paid at 50%

Hospitalization and preventive care paid at 100%;other basic benefits paid at 75%


Basic, including 100%Part B coinsurance, except up to

$20 copayment for office visit and up to$50 copayment

for ER

Skilled Nursing Facility

Coinsurance


Coinsurance


Coinsurance

Skilled Nursing Facility Coinsurance

50% Skilled Nursing Facility

Coinsurance

75% Skilled Nursing Facility

Coinsurance


Coinsurance


Coinsurance

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

50% Part A Deductible

75%Part A Deductible

50%Part A Deductible

Part A Deductible

Part B Deductible

Part B Deductible

Part B Excess (100%)

Part B Excess (100%)

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Foreign Travel

Emergency

Out-of-pocket limit$4,960:

Paid at 100% after

limit reached

Out-of-pocket limit$2,480:

Paid at 100% after

limit reached

*Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as P lan F after one has paid a calendar year $2,200 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,200. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible. Please note: High Deductible Plan F is currently not available as part of this program. MS8510GOT TXFB TLIC TX Farm Bureau MIPPA-Outline

Transamerica Life Insurance Company

Medicare Supplement Plans

About Your Certificate

Premium Information We, Transamerica Life Insurance Company, can only raise your premium if we raise the premium for all certificates like yours in this state.

Disclosures Use this outline to compare

benefits and premiums among policies.

Read Your Certificate Very Carefully

This is only an outline describing your certificate's most important features. The certificate is your insurance contract. Youmust read the certificate itself to understand all of the rights and duties of both you and Transamerica Life Insurance Company.

Right to Return Certificate If you find you are not satisfied

with your certificate, you may return it to Transamerica Life Insurance Company, 2700 West Plano Parkway, P l a n o , TX 75086-9915. If you send the certificate back to us within 30 days after you receive it, we will treat the certificate as if it had never been issued and return all of your payments.

Certificate Replacement If you are replacing another

health insurance Certificate, do NOT cancel it until you have actually received your new Certificate and are sure you want to keep it.

Notice

The Certificate may not fully cover all of your medical costs.

Transamerica Life Insurance Company is not connectedwith Medicare.

This Outline of Coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult "Medicare and You" for more details.

Exclusions Coverage is not provided for any

expenses which are not Medicare approved, except as otherwise specified.

Pre-existing Conditions No benefits will be provided

during the first six months from the effective date of coverage for any sickness or injury for which you were treated or advised by a physician during the six months prior to the effective date of coverage.

If you are an Eligible Person for Guaranteed Issue we will not exclude benefits based on a Pre-Existing Condition.

If you turned 65yearsof age and have applied for Medicare Part B coverage within the last six (6) months, and were covered by prior creditable coverage without a break of over sixty-three (63) days, or if this coverage replaces creditable coverage, such as in- force Medicare Supplement or primary hospital and medical reimbursement insurance coverage that has been in-force within the past 63 days, then this pre-existing conditions, limitation will be waived to the extent it was satisfied under the prior creditable coverage.

Refundof Premiums Transamerica Life Insurance

Company will promptly refund to the policyholder, anyunearned premium upon your death or upon cancellation of the policy or your certificate.

Complete Answers Are Very Important

When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. We may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

Plan A

STD-A

MEDICARE (PART A) - HOSPITALSERVICES - PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility or 60days in a row.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneousservices and supplies

First 60 days

61st thru90th

day 91

st

dayand after: While using 60 lifetime reserve days Once lifetime reserve days are used:

Additional 365 days

Beyond the Additional 365 days

All but $1,316

All but $329 a day

All but $658 a day

$0

$0

$0

$329 a day

$658 a day

100%of Medicare eligible expenses

$0

$1,316

(Part A Deductible) $0

$0

$0**

All costs

SKILLED NURSING FACILITY CARE*

All approved amounts

$0

$0

You must meet Medicare's requirements, including Having been in a hospital for at least 3daysand entered a Medicare approved facility within 30 days after leaving the hospital:

First 20 days 21st thru100th day All but $164.50 a day $0 Up to $164.50 a day 101st day and after $0 $0 All costs

BLOOD $0

3 pints

$0 First 3 pints

Additional amounts 100% $0 $0

HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness.

All butverylimited

copayment/coinsurance for outpatient drugs and

inpatient respite care

Medicare

copayment/ coinsurance

$0

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicarewouldhavepaidforanadditional365daysas provided in the policy’s “Core Benefits”. During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

Plan A

STD-A

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Medicare Part B Deductible will have been met for the calendar year.


MEDICAL EXPENSES - IN OR OUT OF THE

$0

$0

$183

HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician's services, Inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, Diagnostic tests, durable medical equipment:

First$183 of Medicare-Approved Amounts* (Part B Deductible)

Remainder of Medicare-Approved Amounts Generally 80% Generally 20% $0

PART B Excess Charges (Above Medicare- Approved Amounts)

$0

$0

All costs

BLOOD $0

All costs

$0 First 3 pints

First $183 of Medicare-Approved Amounts* $0 $0 $183 (Part B Deductible)

Remainder of Medicare-Approved Amounts 80% 20% $0

CLINICAL LABORATORYSERVICES TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A& B

HOME HEALTHCARE MEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies Durable medical equipment:

First$183 of Medicare-Approved Amounts*

Remainder of Medicare-Approved Amounts

100%

$0

80%

$0

$0

20%

$0

$183 (Part B Deductible)

$0

Plan F

STD-F


*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.


HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneousservices and supplies:

First 60 days

61st thru90th day 91st dayandafter:

While using 60 lifetime reserve days Once lifetime reserve days are used:

Additional 365 days (lifetime)


All but $1,316

All but $329a day

All but $658a day

$0

$0

$1,316

(Part A Deductible) $329 a day

$658 a day

100%of Medicare Eligible Expenses

$0

$0

$0

$0

$0**

All

SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital:

First 20 days

21stthru100th day 101st day and after


All but $164.50 aday $0

$0

Up to$164.50 a day $0

$0

$0 All costs

BLOOD $0

3 pints

$0 First 3 pints



All but very limited copayment/coinsurance for outpatient drugs

and inpatient respite care

Medicare copayment/ coinsurance

$0

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for anadditional365 days as provided in the policy's "Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

Plan F

STD-F

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

*Once you have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.


MEDICAL EXPENSES - IN OR OUT OF THE

$0

Generally 80%

$183

(Part B Deductible) Generally 20%

$0

$0

HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, Diagnostic tests, durable medical equipment:

First $183 of Medicare-Approved Amounts*


PART B Excess Charges (Above Medicare-Approved Amounts)

$0

100%

$0

BLOOD $0 $0

80%

All costs $183

(Part B Deductible) 20%

$0 $0

$0

First 3 pints Next $183 of Medicare-Approved Amounts*


CLINICAL LABORATORYSERVICES TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTSA& B

HOME HEALTHCARE

Medicare Approved Services:

Medically necessary skilled care services and medical supplies Durable medical equipment:



100%

$0

80%

$0

$183 (Part B Deductible)

20%

$0

$0

$0

OTHER BENEFITS- NOT COVERED BY MEDICARE

FOREIGN TRAVEL Medically necessary emergency care beginning during the first 60 days of each trip outside the USA:

First $250 each calendar year Remainder of charges

$0 $0

$0

80%to a lifetime

maximum of $50,000

$250

20% and amounts over the $50,000 lifetime maximum

Plan N

STD-N


*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.


HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneousservicesand supplies:

First 60 days

61st thru90th day 91st dayand after:

While using 60 lifetime reserve days Once lifetime reserve days are used:

Additional 365days (lifetime)


All but $1,316

All but $ 329 a day All

but $ 658 a day

$0

$0

$1,316

(Part A Deductible) $329 a day

$658 a day

100%of Medicare Eligible Expenses

$0

$0

$0

$0

$0**

All costs

SKILLED NURSING FACILITY CARE*


All but$164.50 a day $0

$0

Up to$164.50 a day $0

$0

$0 All costs

You must meet Medicare's requirements, including Having been in a hospital for at least 3daysand entered a Medicare- approved facility within 30 days after leaving the hospital:

First 20 days

21stthru100th day 101st day and after

BLOOD $0

3 pints

$0 First 3 pints



All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/ coinsurance

$0

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for anadditional365daysas provided in the policy's ”Core Benefits." During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

Plan N

STD-N

MEDICARE (PARTB) - MEDICAL SERVICES - PER CALENDARYEAR *Once you have been billed $183 of Medicare-Approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.


MEDICAL EXPENSES - IN OR OUT OFTHE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment:


Remainder of Medicare- Approved Amounts

$0

Generally 80%

$0

Balance, other than up to $20 per office visit and

up to $50 per emergency room visit. The copayment of up

to $50 is waived if the insured is admitted to any hospital and the emergency visit is

covered as a Medicare Part A expense.

$183(Part B Deductible)

Up to $20 per office visit and up to $50

per emergency room visit. The copayment of $50 is waived if the insured is admitted to any hospital and the emergency visit

is covered as a Medicare Part A expense.

Part B ExcessCharges (Above Medicare-Approved Amounts)

$0

$0

All Costs

BLOOD

$0 $0

80%

All costs $0

20%

$0 $183 (Part B

Deductible) $0

First 3 pints First $183of Medicare-Approved Amounts*


CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTSA& B HOME HEALTHCARE MEDICARE-APPROVED SERVICES:

Medically necessary skilled care services And medical supplies Durable medical equipment:

First $183 of Medicare-Approved Amounts* Remainder of Medicare-Approved Amounts

100%

$0

80%

$0

$0

20%

$0

$183(Part B Deductible

20%

OTHER BENEFITS- NOT COVERED BY MEDICARE

FOREIGN TRAVEL - NOT COVERED BYMEDICARE Medically necessary emergency care services Beginning during the first 60 days of each trip outside the USA:

First $250 each calendar year Remainder of charges

$0 $0

$0 80%toalifetime

maximum of $50,000

$250 20%and

amounts over the$50,000

lifetime maximum

Medicare Supplement Protection Insurance Application FormUnderwritten by Transamerica Life Insurance Company, Cedar Rapids, IA 52499

TO APPLY:1. Check the Plan you want. Complete and sign the form below. Make sure you answer all the questions and read all the

statements.2. Enclose your check for your first premium payment for the Plan you've chosen. Make it payable to Transamerica Life

Insurance Company.

MEMBER INFORMATION SPOUSE INFORMATION (IF APPLYING)

o I wish to enroll Sex: o Male o FemaleYour date of Birth:_______________ (Month/Day/Year)

Height: ____________ Weight: ____________Telephone #: __________________________Your Social Security #:_______-_______-_______Medicare ID #: ______________ (Found on your Medicare I.D. Card)

o My Spouse wishes to enrollSpouse's Name:_________________________________Spouse's Date of Birth: _________________ (Month/Day/Year)

Height: ____________ Weight: ____________Spouse's Social Security #:_______-_______-_______Medicare ID #: ______________ (Found on your Medicare I.D. Card)

PLAN APPLYING FOR

Member: o Plan A o Plan F o Plan NSpouse: (if applying): o Plan A o Plan F o Plan N

Mode of Payment: o Annual o Semi-Annual o Quarterly o Monthly (monthly requires bank draft)Method of Payment: o Direct Bill o Draft Bank Account - please complete authorization information

Desired Effective Date of Coverage: _________________________________________________________

PLEASE ANSWER THESE QUESTIONSIf you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligiblefor guaranteed issue of a Medicare supplement insurance policy, or that you had certain rights to buy such a policy, you maybe guaranteed acceptance in one or more of our Medicare supplement plans. Please include a copy of the notice from yourprior insurer with your application.

PLEASE ANSWER ALL QUESTIONS. To the best of your knowledge. Member Spouse

(if applying)(1) What is the effective date of your Medicare Part B coverage (as shown on your

Medicare ID card)?

___/ ___/ ___mo./ day/ year

___/ ___/ ___mo./ day/ year

(2) Did you disenroll or were you terminated by your prior insurance plan?(a)YES, what is the date of disenrollment or termination.(Please refer to the last page for the definition of Eligible Person and Creditable Coverage.)

Please attach a copy of the termination letter you received from your prior carrier.

o Yes o No___/ ___/ ___mo./ day/ year

o Yes o No___/ ___/ ___mo./ day/ year

(3) Your Acceptance May be Guaranteed

(a) Did you turn age 65 in the last 6 months?(b) Did you enroll in Medicare Part B in the last 6 months?(c) If yes, what is the effective date? ___________________________(d) Are you covered for medical assistance through the state Medicaid program?

o Yes o Noo Yes o No____ monthso Yes o No

o Yes o Noo Yes o No____ monthso Yes o No

NAME _____________________________________

ADDRESS__________________________________

__________________________________________

Transamerica Life Insurance Company Medicare Supplement Application

Agent Number MZ0927361H

MS8500GAT C03-V218 Page 1 of 7 5483715

kskinner

Typewritten Text

kskinner

Typewritten Text

SpouseMemberPLEASE ANSWER THESE QUESTIONS: (CONTINUED)(NOTE TO APPLICANT: If you are participating in a "Spend-Down Program" and havenot met your "Share of Cost," please answer NO to this question.) If yes,(a) Will Medicaid pay your premiums for this Medicare supplement policy?(b) Do you receive any benefits from Medicaid OTHER THAN payments toward yourMedicare Part B premium? ______________________________

o Yes o Noo Yes o Noo Yes o No

o Yes o Noo Yes o Noo Yes o No

(4) If you had coverage from any Medicare plan other than original Medicare within thepast 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO),fill in your start and end dates. If you are still covered under this plan, leave "END"blank.(a) If you are still covered under the Medicare plan, do you intend to

replace your current coverage with this new Medicare supplement policy?(b) Was this your first time in this type of Medicare plan?(c) Did you drop a Medicare supplement policy to enroll in this Medicare plan?

(5) Do you have another Medicare supplement policy in force?(a) If so, with what company, and what plan do you have?___________________________________________________(b) If so, do you intend to replace your current Medicare supplement policy

with this policy?

(6) Have you had coverage under any other health insurance within the past 63 days?(For example, an employer, union, or individual plan?(a) If so, with what company and what kind of policy?___________________________________________________(b) What are your dates of coverage under the other policy? If you are still covered

under the other policy, leave "END" blank.

Start _______End _______

o Yes o Noo Yes o Noo Yes o Noo Yes o No

o Yes o No

o Yes o No

Start _______End _______

Start _______End _______

o Yes o Noo Yes o Noo Yes o Noo Yes o No

o Yes o No

o Yes o No

Start _______End _______

Health QuestionsPlease Answer The Following Medical Questions. All "Yes" responses must be explained in the space providedbelow question 6. Any "Yes" response may result in a policy not being issued. (If application is made during yourMedicare open enrollment period or you are an Eligible Person, you should NOT complete these questions)

(1) Are you currently confined in a hospital or nursing home, or in the last 12 months haveyou been confined in a hospital or nursing home or received home health care?

o Yes o No o Yes o No

(2) Are you currently bedridden, confined to a wheelchair, or during the past two years,have you had any type of amputation caused by disease?


(3) During the last two years, has a physician or other medical practitioner diagnosed youwith or treated you for ANY of the following: HIV Infection, AIDS or AIDS RelatedComplex (ARC), Alzheimer´s Disease or Dimentia, Cirrohsis of the Liver, Emphysemaor other respiratory Problem, Hodgkin´s Disease, Diabetes requiring Insulin Injection,Cancer (other than Skin Cancer), Multiple Sclerosis, Parkinson´s Disease, Stroke,Alcoholism or Drug Abuse, Transient Ischemic Attack (TIA), or Myocardial Infarction?


(4) During the last two years, have you had or been advised to have Heart tests, HeartSurgery or Kidney Dialysis, or any Organ Transplant?


(5) During the last two years have you been advised to have surgery, take medication,have treatments, or have hospital or nursing facility confinement?


MS8500GAT Page 2 of 7

(6) List below ALL prescription medication you are currently taking or have taken within the past 6 months._______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Please provide detailed explanation of all "Yes" answers to questions 1 – 5 above. Use an additional sheet (must besigned and dated) if necessary.

#Nature of Condition and Diagnosis How Long Treated or Confined?

Name, address, and PhoneNumber of Treating Physicianand Hospital or Nursing Home

Medicare Supplement Information to Considerl You do not need more than one Medicare Supplement policy.

l If you purchase this Policy, you may want to evaluate your existing health coverage and decide if you need multiplecoverages.

l You may be eligible for benefits under Medicaid and may not need a Medicare Supplement policy.

l If, after purchasing this certificate, you become eligible for Medicaid, the benefits and premiums under your Medicaresupplement certificate can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months.You must request this suspension within 90 days of becoming eligible for Medicaid. If you are no longer entitled to Medicaid,your suspended Medicare supplement certificate (or, if that is no longer available, a substantially equivalent policy orcertificate) will be reinstituted if requested within 90 days of losing Medicaid eligibility. If the Medicare supplement certificateprovided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your certificate wassuspended, the reinstituted certificate will not have outpatient prescription drug coverage, but will otherwise be substantiallyequivalent to your coverage before the date of the suspension.

l If you are eligible for, and have enrolled in a Medicare supplement certificate or policy by reason of disability and you laterbecome covered by an employer or union-based group health plan, the benefits and premiums under your Medicaresupplement certificate or policy can be suspended, if requested, while you are covered under the employer or union-basedgroup health plan. If you suspend your Medicare supplement certificate or policy under these circumstances, and later loseyour employer or union-based group health plan, your suspended Medicare supplement policy (or, if that is no longeravailable, a substantially equivalent certificate or policy) will be resinstituted if requested within 90 days of losing youremployer or union-based group health plan. If the Medicare supplement certificate or policy provided coverage for outpatientprescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not haveoutpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of thesuspension.

l Counseling services may be available in your state to provide advice concerning your purchase of Medicare supplementinsurance and concerning medical assistance through the state Medicaid program, including benefits as a QualifiedMedicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB).

IMPORTANT - PLEASE READ AND SIGNI hereby apply for Medicare Supplement coverage issued by Transamerica Life Insurance Company. I understand that thiscoverage will not pay benefits for conditions for which I have received medical treatment or advice within the last 6 monthsprior to the effective date until I have been insured for 6 consecutive months. If this plan replaces creditable coverage, suchas Medicare Supplement Insurance or primary hospital and medical reimbursement coverage, that has been in-force withinthe past 63 days, then the pre-existing conditions limitation will be waived to the extent it was satisfied under the replacedcoverage. If I am an Eligible Person for Guaranteed Issue, the pre-existing condition limitation will be waived.

Member's Signature X_____________________________ Date ___________________

Spouse's Signature (if applying) X________________________ Date ___________________

PLEASESIGNHERE

MAIL TO:Insurance Marketing ServicesP.O. BOX 2689Waco, TX 76702-2689

Your 30 Day Right To Review Your Policy Takes The Risk Out Of Applying NowFor more information, call our Toll-Free Insurance

Hotline for prompt, courteous service. ( 800-999-8932


Agent Information and Certifying StatementsTO BE COMPLETELY FILLED OUT AND SIGNED BY THE AGENT IN ALL CASES

Have you or your agency sold any other health or disability insurance policies to the applicant now or in the past?o Yes o NoIf yes,1. List policies still in force:_________________________________________________________________________2. List policies sold within the past 5 years which are no longer in force:_________________________________________________________________________3. Is the applicant a member of the Texas Farm Rural Health Association?If yes, please list membership #_________________

I, the agent, certify that I have asked whether the applicant is currently insured under any existing Medicare Supplementinsurance policy or any other health policy. I acknowledge that I verified that the applicant has or has applied for Medicare PartB and hereby witness the applicants signature for the effective date of that coverage. I understand that I have no right to bindthis coverage, to alter the terms of the Insurance Policy or Application in any manner, or to adjust any claim for the benefitsunder the Insurance Policy._____________________________________________________________________________________________________

Signature of Agent:____________________________________________________ Date:_____________________

Writing Agent’s Name (Please Print):______________________________________

Agent’s Texas License Number:__________________________________________ Agent’s Code:______________


AUTHORIZATIONTO DRAFT BANK ACCOUNT

o YES, I would like my (and/or spouse) insurance premiums automatically withdrawn from my bank account each month.

-IMPORTANTFor Checking Account withdrawals, please include a voided blank check (write"VOID" across the blank check)

with this application and sign the authorization agreement.

Pre-Authorization Payment Agreement

I hereby authorize you to electronically charge my account for premium debits to Transamerica Life Insurance Company,Baltimore, Maryland. I understand that my account will be charged according to the deduction date that I have chosen. If I donot choose a specific day, the deduction will be made on the first of each month. I agree that this electronic payment shall beregarded the same as if it were a check written by me and drawn on my account. This authorization is to remain in effect untilrevoked by me in writing.

I understand that credit for the payment is conditioned upon the order being honored when presented. I understand that thisauthorization may be terminated: (1) at the option of Transamerica Life if any debit is not honored when presented for payment,or (2) upon thirty (30) days written notice given by Transamerica Life, the bank or me.

X__________________________________________Signature of Account Holder(s)

Please complete the following information: 1. My Account is: o Checking o Savings 2. Name of Bank or Institution:______________________________________ 3. Bank or Institution ABA Routing Number:____________________________ 4. Account #: _________________________ 5. Please make my deduction on the __________ day of each month.

(1st - 28th)

MS8500GAT Page 5 of 7 5483715

Date:_____________________

If you have chosen a Monthly Bank Draft Payment Mode, please complete the following Authorization and attach a voided check. If paying other than monthy, DO NOT complete the following Authorization.

PREAUTHORIZED DRAFT AUTHORITY FOR MONTHLY PAYMENT MODE

Please be sure to submit a voided check with this application.

TRANSAMERICA LIFE INSURANCE COMPANY or its administrator GILSBAR, LLC.

I have authorized __________________________ Bank, or __________________________, to honor electronic debit entries or drafts on my account by you to cover premiums insuring _________________________. Such debit entries or drafts are to be charged to my account with said bank in the same manner as if they were drawn personally by me.

It is understood that such debit or draft shall constitute notice of premium due. Should any such debit or draft not be paid by said bank for any reason, it will be the responsibility of the Insured to make arrangements with the Company for premium payments with the grace period to prevent lapse due to nonpayment. It is also understood that the Company assumes no responsibility for bank charges on these draws. Signed this _____ day of _____, 20_____

________________________________________________ ________________________________________________Bank Account Number Transit / Routing Encoding

Draft Date:___________________________________________________________________________________________(Select any day except 29th, 30th, or 31st of each month)

____________________________________________________________________________________________________ Print Name of Premium Payor as used for Bank Account

____________________________________________________________________________________________________ Signature of Premium Payor as used for Bank Account

AUTHORIZATION TO HONOR ACH DEBIT ENTRIES OR DRAFTS DRAWN BY GILSBAR, LLC.

TO: ____________________________________________________________________________________________ Bank

BANK ADDRESS:_____________________________________________________________________________________

As a convenience to me, I hereby request and authorize you to pay and charge to my account debit entries or drafts drawn on my account and payable to the order of GILSBAR, LLC, provided there are sufficient collected funds in said account to pay the same upon presentation. I agree that your rights in respect to each such debit entry or draft shall be the same as if it were a check drawn on you and signed personally by me. This authority is to remain in effect until revoked by me in writing, and until you actually receive such notice I agree that you shall be protected in honoring any such debit entry or draft.

I further agree that if any such debit or draft be dishonored, whether with or without cause and whether intentional orinadvertently, you shall be under no liability whatsoever even though such dishonor results in forfeiture of insurance.


Questions?Please call a Friendly Customer Service Associate Toll-Free at:

( 800.999.8932Monday through Friday, 8:00 a.m. to 5:00 p.m., Central Time


Definitions

Creditable Coverage - means a self-funded or self-insured employee welfare benefit plan that provides health benefits inaccordance with the Employee Retirement Income Security Act of 1974; a group health benefit plan; health insurancecoverage; Part A or B of Title XVIII of the Social Security Act; Title XIX of the Social Security Act, other than coverageconsisting solely of benefits under The 1928 of that Act; Chapter 55 of Title 10 United States Code (TRICARE); a medical careprogram of the Indian Health Service or of a tribal organization; a state health benefits risk pool; a health plan offered underChapter 89 of Title 5 United States Code (Federal Employees Health Benefits Program); a public health plan as defined infederal regulation; a health benefit plan under Section 5(e) of the Peace Corps Act; or short-term limited duration insurance asdefined in federal regulation.

Eligible Person for Guaranteed Issue - means an individual described in any of the following statements:1. enrolled under an employee welfare benefit plan that either: (a) supplements Medicare, and the plan terminates or ceases

to provide all such benefits; or (b) is primary to Medicare and the plan terminates or ceases to provide all health benefits tothe individual because the individual leaves the plan;

2. enrolled in a Medicare Advantage plan under Part C of Medicare or the individual is 65 years of age or older and is enrolledwith a Program of All-Inclusive Care for the Elderly (PACE) provider and the organization's certification or plan isterminated or specific circumstances permit discontinuance including, but not limited to, a change in residence of theindividual, the plan is terminated for all individuals within a residence area, the organization substantially violated a materialpolicy provision, or a material misrepresentation was made to the individual;

3. enrolled in a Medicare risk or cost contract, health care prepayment plan, or Medicare Select plan, or similar organization,and the organization's certification or plan is terminated or specific circumstances permit discontinuance including, but notlimited to, a change in residence of the individual, the plan is terminated for all individuals within a residence area, theorganization substantially violated a material policy provision, or a material misrepresentation was made to the individual;

4. enrolled in a Medicare Supplement policy and coverage discontinues due to insolvency of the issuer or bankruptcy of thenonissuer organization; or of other involuntary termination of coverage or enrollment under the policy, substantial violationof a material policy provision, or material misrepresentation;

5. enrolled under a Medicare Supplement policy, terminates enrollment and subsequently enrolls, for the first time, in aMedicare Advantage plan under Part C of Medicare or any similar organization, a Medicare risk or cost contract, any PACEprovider, or a Medicare Select plan, and the insured person subsequently terminates coverage within 12 months ofenrollment; or

6. upon first becoming eligible for benefits under Medicare Part B at age 65 or older, enrolled in a Medicare Advantage planunder Part C of Medicare or with a PACE provider and disenrolls no later than 12 months after the effective date ofenrollment.

7. enrolled in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Part D, was enrolledunder a Medicare Supplement policy that covers outpatient prescription drugs and the individual terminates enrollment inthe Medicare Supplement policy and submits evidence of enrollment in Medicare Part D along with the application for apolicy that has a benefit package classified as Plan A, B, C, F (including F with a high deductible), K, or L, and that isoffered and is available for issuance to new enrollees by the same issuer that issued the individual's Medicare supplementpolicy with outpatient prescription drug coverage.

8. loses eligibility for health benefits under Title XIX of the Social Security Act (Medicaid).

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