Dental & Vision Coverage
 Participant     Participant +1     Participant +2+ (Family)
SAG-AFTRA Health Plan
 Plan I    Plan II
 
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)
SAG-AFTRA Member ID
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 10/01/2018

DEPENDENT INFORMATION

(Enter dependent information if applicable)

 

NAME

 

SEX

 

RELATIONSHIP

 

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

 

DEPENDENT SIX INFO: 

First Name 

Last Name 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 

DEPENDENT SEVEN 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:

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.