Please complete the following if paying with a checking account:
Bank Name:
Name on Account:
Routing Number:

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)
Card CVV Security Code:
Expiration Month:
Year:
This is
not standard disclaimer, so please read it carefully:
In order to participate in this supplemental plan you must be covered by the SAG-AFTRA Health Plan I or Plan II. If your status changes, please notify our office directly at 800-450-1271.
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 quarter. 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 SAG-AFTRA 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 Cigna Insurance Company within 10-14 business days of your enrollment.