ROA-Sponsored Insurance Plans
Information Request Form

Please mail my FREE Information Packet(s) on the following ROA-sponsored Plans:
ReserveCare Tricare Supplements 1-800-247-7988
ReserveCare Hospital Income Plan 1-800-247-7988
Group Term Life Plan 1-800-247-7988
Joint Term Life Plan 1-800-247-7988
Cancer Plan 1-800-247-7988
Accident Plan 1-800-247-7988
Short Term Recovery 1-800-626-6983
Long Term Disability Plan 1-800-247-7988
Excess Major Medical Plan 1-800-247-7988
Accidental Disability Plan 1-800-247-7988

To request your free information packet (including costs, exclusions, limitations and terms of coverage) on the plans listed below, please call the phone number beside the plan name.
Long Term Care Solutions Network 1-800-882-6035
Short Term Medical Plan 1-800-323-2106
HealthMart Plans 1-800-503-9230
Gateway Plans 1-800-282-4495

Please fill in all information:

* FIRST NAME:
* LAST NAME:
ROA MEMBER NUMBER:
E-MAIL ADDRESS:
* STREET ADDRESS:
STREET ADDRESS:
* CITY:
* STATE:
* ZIP CODE: -
DATE OF BIRTH: DAY MONTH YEAR

* Required information. Your request cannot be submitted unless all required information is completed.

When you have completed all information requested above, submit your request and your Information Packet(s) will be mailed to your address. This information cannot be sent electronically.

Coverage may not be issued to residents of all states.