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General Information
View Domestic Partnership Form

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Coverage Amount Requested

Spouse/Domestic Partner Coverage Amount Requested

Beneficiary Designation for Member Coverage

Member is automatically designated as the beneficiary for spousal coverage.


Coverage Questions

The Monthly Benefit Amount cannot exceed $ 1,600 or 67% of your gross monthly salary, whichever is less.

1
Have you been actively engaged in the full-time duties (at least 30 hours per week) of your occupation for the 90-day period immediately before the date of this application?
2
Do you have any Disability Income Insurance in force or pending in this (New York Life) or any other company? If yes, give detail.
3
Is the Monthly Benefit Amount herein applied for equal to or less than 67% of your Basic Monthly Pay minus any Other Income Benefits?
1
Have you been actively engaged in the full-time duties (at least 30 hours per week) of your occupation for the 90-day period immediately before the date of this application?
2
Do you have any Disability Income Insurance in force or pending in this (New York Life) or any other company? If yes, give detail.
3
Is the Monthly Benefit Amount herein applied for equal to or less than 67% of your Basic Monthly Pay minus any Other Income Benefits?
Payment Options

 

I hereby authorize Government Employees’ Benefit Association, Inc. (GEBA) to debit my checking/savings account according to the published schedule. I understand that GEBA reserves the right, upon written notification, to terminate my participation in this payment option. If an automatic debit is returned for any reason including insufficient funds, closed or unauthorized account, GEBA will not be able to process payment. I understand that I may be subject to a $20 charge if payment is rejected, reversed, or refused by my financial institution. I may cancel participation in the GEBA Automatic Debit service with written notice 10 days prior to the premium due date.

Fraud Notice

Authorization

To be eligible for this limited-time offer, you must be age 60 or younger and not currently insured under this disability plan for a monthly benefit in excess of $1,600 and apply within 60 days of your hire date.

Moreover, you are not eligible for this offer if:

  • You are currently on waiver of premium
  • Your last application was declined for medical reasons

By signing and dating this application, I request the insurance indicated, attest to having read the Fraud Notice above, and that to the best of my knowledge and belief, the answers to the questions are true and complete.

Electronic Enrollment Signature

THE FOLLOWING TERMS AND CONDITIONS GOVERN YOUR USE OF THE ONLINE ENROLLMENT.

IF YOU AGREE WITH THESE TERMS AND CONDITIONS, PLEASE CLICK THE ACCEPT BUTTON BELOW.

By clicking the accept button below, I acknowledge that I read, understand and agree with all the following statements:

  • I agree to the usage of electronic signature and electronic records for current and future transactions pertaining to my enrollment conducted through GEBA’s website, effective on the date I click on the “Accept” button.
  • I understand that I have the option to print and retain paper copies of any electronic records generated and to obtain paper copies of any electronic records generated during website transactions concerning my coverage(s).
  • I understand that to obtain paper copies of electronic records kept by GEBA concerning my coverage(s), or to withdraw my consent prospectively only to the usage of electronic records, I must contact GEBA.
  • I understand that in the event my personal contact information changes or any error is detected, I must immediately notify GEBA of the changes.
  • I understand that to access and conduct transactions relating to my coverage via www.GEBA.com internet site, I must have access to a personal computer at my home or workplace, which is capable of supporting internet access and a compatible browser application.

BY CLICKING THE “ACCEPT”, YOU ACKNOWLEDGE THAT YOU AGREE TO THE ELECTRONIC DELIVERY OF THE AGREEMENT AND TO BE LEGALLY BOUND WITH RESPECT TO THIS AGREEMENT AS IF YOU HAD SIGNED THIS AGREEMENT WITH A HAND WRITTEN SIGNATURE. YOU MAY PRINT AND RETAIN A COPY OF THIS AGREEMENT FOR YOUR RECORDS.



G-29344-0



GMA-GI
LTDI-NH
6/14 ed.