Dental Coverage
None    PPO    DHMO   (DHMO available in CA,CO,FL,IL,IN,MI,MO,NJ,NY,OH)
Vision Coverage
None    VSP   
First Name
Middle Initial
Last Name
Marital Status
Single Married Legally Separated Divorced
Date of Birth
(mm/dd/yyyy)
Gender
   Male Female
Social Security Number
(no dashes, numbers only)

DHMO Dentist ID#

(DHMO Participants must enter their Primary Care Dentist ID#.)   (What is this?)
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail
Create a log-in Password
(Used for later online access)
Effective Enrollment Date 01/01/2018

ENROLLMENT OF DEPENDENT INSURANCE

(Select Dependent Coverage and enter dependent information if applicable)

 

I Elect Dependent Coverage For:  None   spouse only   spouse & child(ren)   child(ren) only

 

NAME

 

SEX

 

RELATIONSHIP

 

SSN

 

BIRTH DATE

 

STUDENT

 

DEPENDENT ONE INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

Yes

No

 

DEPENDENT TWO INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

Yes

No

 

DEPENDENT THREE INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

Yes

No

 

DEPENDENT FOUR INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 

DEPENDENT FIVE INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 


Please Select Method of Payment

Checking Account   Credit Card


Please complete the following if paying with a checking account:

Bank Name:

Name on Account:

Routing Number:    checkGuide

Account Number:  

 

 

 

 

 


Please complete the following if paying with a Visa or Master Card (we do not accept American Express or Discover):

Name on Account:

Card Number:       (no dashes, numbers only)CV2image

Card CVV Security Code:      

Expiration Month:   Year:

 


This is not standard disclaimer, so please read it carefully:

The premiums for this program are collected in advance of the month that they are due.  Premium must be paid via automatic collection by credit card or bank draft. Your initial premium due will be collected within 5 business days of the application. Subsequent premiums will be collected on the 15th of the month prior to the start of the next month.  There will be no invoicing of premium; premium will ONLY be collected electronically.

You are authorizing Babbitt Municipalities, Inc. (d.b.a. Group Benefit Associates) to draft a checking account or charge a credit card for the purpose of collecting premiums for the Dental and Vision policy.  Final approval in this program is subject to verification of membership and good standing in the Union.  The act of collecting a premium to your credit card or bank account does not constitute coverage. 

You will receive an ID card directly from the Guardian Insurance Company within 10-14 business days of your enrollment.