Member Information

Social Security Number
(no dashes, numbers only)
First Name
Middle Initial
Last Name
Date of Birth
   Male Female
Union or Badge Number
Union Initiation Date
Hourly Wage Rate
Street Address
Address (cont.)
Zip/Postal Code
Create a log-in Password
  (used for later online access)

Select Coverage

Elect Coverage
Income Benefit
Premium Amount
 Short Term Disability
 Long Term Disability


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 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. 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.

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

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
  • 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
  • Within 30 days if I withdraw from the Union

Any data that you submit to Group Benefit Associates through this website will be processed and used as described in the Privacy Policy available at the following link: Privacy Policy. By checking the box to the left, you agree that you have read and understood the terms of the Privacy Policy, and that you are granting Group Benefit Associates permission to use your data in accordance with the terms of the Privacy Policy.