Member Information

 
Social Security Number
(no dashes, numbers only)
First Name
Middle Initial
Last Name
Marital Status
Single Married Legally Separated Divorced
Date of Birth
(mm/dd/yyyy)
Gender
   Male Female
SAG-AFTRA Union Number
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail
Create a log-in Password

Dependent Information

(Complete for Coverage of Spouse and Children)

 

LIST EACH DEPENDENT NAME (LAST, FIRST, MIDDLE INITIAL)

 

SEX

 

SSN

 

BIRTH DATE

 

STUDENT

 

 DEPENDENT ONE: 

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

Yes

No

 

 DEPENDENT TWO:

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

Yes

No

 

 DEPENDENT THREE:

 

F

M

 

 

 

 

(mm/dd/yyyy)

 

Yes

No

 

  DEPENDENT FOUR:

 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No

 

  DEPENDENT FIVE:

 

 

F

M

 

 

 

 

(mm/dd/yyyy)

Yes

No


 

Select Benefit Amount

 
Benefit Amount
Premium Amount
Elect Coverage
 Member
 Spouse
 Children
 
Total 
 

 

Designated Beneficiary(s)

 Primary:           Name (Last, First, Middle)
Relationship
%
 
 
 Secondary:
 
 
 
  Additional Information:    
 

 


Please Answer the following Medical Question:

For any of the above Insured: In the last 6 months, have you or any of your dependents received medical treatment, consultation, care or services, including diagnostic measures or took prescribed drugs for: cardiovascular disease; cancer; any condition related to Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex; or any other life threatening condition?

Yes                No

AN EVIDENCE OF INSURABILITY FORM(S) MUST BE COMPLETED FOR ANY EMPLOYEE OR DEPENDENT(S) WITH A “YES” ANSWER TO THE ABOVE QUESTION. PLEASE CONTACT OUR OFFICE FOR MORE INFORMATION.

 


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 CVV2 Security Code:      

Expiration Month:   Year:

 


In order to participate in this plan you must be and remain current with any union dues AND maintain SAG-AFTRA Health coverage.  If your status with the union or SAG-AFTRA Health changes at any time, 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.  Your initial premium due will be collected within 5 business days.  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 collect your premium directly from your checking account or credit card.  The act of collecting a premium from your checking account or credit card does not constitute coverage.