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
(optional)
Union Initiation Date
(mm/dd/yyyy) (optional)
Hourly Wage Rate
Total Premium:
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Phone
E-mail
Create a log-in Password
  (used for later online access)


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:

 


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 this policy. 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.

I am hereby enrolling in the Voluntary Group Disability Income Insurance Plan. Final approval in this program is subject to Union verification.  The act of collecting a premium to your credit card or bank account does not constitute coverage. 

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

  • Within 60 days of any layoff and again within 60 days of my subsequent return to work
  • Immediately when my payment method changes for the purpose of premium collection
  • Immediately when my wage rate changes
  • Within 1 year of my date of disability if I become disabled