Your session will expire in one minute. If your session expires, any information you enter for this application will not be transferred to any subsequent application you fill out.
Transferring information from one application to another is a service GEBA offers, but only if applications are submitted within 30 minutes of each other.
By providing your email address to us, you expressly consent to receive emails from us. We may use email to communicate with you, to send information that you have requested or to send information about other products or services developed or provided by us, provided that, we will not give your email address to another party to promote their products or services directly to you.
Plan participants may elect coverage for a spouse, domestic partner, and dependent children up to age 26. Coverage for a dependent child cancels immediately upon attainment of age limit 26. List all family members, including spouse/domestic partner and children, to be covered.
Continued Coverage for a Disabled Child: This applies only to the Dependents Insurance you have for a child. The insurance for the child will not end on the date the age limit in the definition of Qualified Dependent is reached if both of these are true:
If these conditions are met, the age limit will not cause the child to stop being a Qualified Dependent. This will apply as long as the child remains so disabled. Please complete the “Statement of Dependent Eligibility” available at www.geba.com.
Residents of New York - IMPORTANT REPLACEMENT INFORMATION: It may not be in your best interest to replace existing life insurance policies or annuity contracts in connection with the purchase of a new life insurance policy, whether issued by the same or different insurance company. A replacement will occur if, as part of your purchase of a new life insurance policy, existing coverage has been, or is likely to be, lapsed, surrendered, forfeited, assigned, terminated, changed or modified into paid-up insurance or other forms of benefits, loaned against or withdrawn from, reduced in value, by use of cash values or other policy values, changed in length of time or in the amount of insurance that would continue or continued with a stoppage or reduction in the amount of premium paid. Prior to completing a replacement transaction, you may want to contact the insurance company or agent who sold you the life insurance or annuity contract that will be replaced to help decide whether the replacement is in you best interest.
Is the insurance applied for intended to replace, discontinue or change an existing policy?
RESIDENTS OF NEW YORK: I have read the Important Replacement Information above.
Is the life insurance applied for intended to replace, in whole or in part, any existing insurance or annuity?
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.
You must include your ABA (Routing) Number for your bank. Use this image to see where your routing number is listed, if you don't already know. An ABA/Routing number is always 9 digits, no letters or punctuation.
Member is automatically designated as the beneficiary for all dependent and spousal coverage.
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.
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:
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.
New Employee: Enrollment is limited to the first 60 days of hire to Federal Agency or Armed Forces Branch. For contractors assigned to NSA-W, enrollment is limited to 60 days for date of assignment.
To view your rate, you must enter your date of birth, coverage amount requested and payment frequency. If you do not have all the required fields, this Rate will remain blank.