General Information

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.


Prior PLI Carrier Information

*Retroactive date – The date that represents the beginning of coverage. Only claims made to the insurer and occurrences that occurred on or after that date will be honored under the current policy. As respect to this program, the retroactive date will be the verifiable date from which your continuous uninterrupted claims-made professional liability coverage commenced, whether with us or another provider.

Your Plan
$1,000,000 Damages/$100,000 Legal Defense
Beneficiary Information

The policy provides an Accidental Death Benefit for a death directly related to the scope of your employment. Please provide a Beneficiary Designation.


Payment Options

Yearly

*Rate includes Surplus Lines Tax.


Authorization

By signing and dating this application, I request GEBA’s CareerGuard® Professional Liability Insurance for which I am eligible as an employee of the federal government in good standing and to the best of my knowledge and belief, the answers to the questions are true and complete. It is also understood that any acts, error or omission, or allegation thereof that occurs prior to the effective date and/or retroactive date of the coverage will not be covered by the policy.

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.



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