Member Information

 
Social Security Number
(no dashes, numbers only)
First Name
Middle Initial
Last Name
Date of Birth
(mm/dd/yyyy)
Gender
   Male Female
Union or Badge Number
Union Initiation Date
(mm/dd/yyyy)
Hourly Wage Rate
Total Premium:
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone
Cell Phone
E-mail
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I am authorizing a payroll deduction for the purpose of collecting premiums for this policy. The premiums for this program are collected for the pay period that they are due. I understand that any inability to process the premium for this policy due to inadequate income for the pay period will result in loss of coverage for that pay period. There will be no invoicing of premiums.

I am here by enrolling in the Voluntary Group Disability Income Insurance Plan. Final approval in this program is subject to Union verification and successful payroll deduction.

As a plan participant, I agree to notify Group Benefit Associates:

  • Within 30 days of any layoff and again within 30 days of my subsequent return to work
  • Within 1 year of my date of disability if I become disabled
  • Immediately when my wage rate changes
  • Within 30 days if I withdraw from the Union
  • Within 30 days if I retire from a CTA position or leave CTA employment