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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.


Your Plan and Payment Options

Plan year is January 1 – December 31.

Coverage can begin at the first of any month. Premium will be prorated based on the effective date (date the policy starts, which you can select below). Effective date is the first day of the following month from the date of application submission. The policy automatically renews in January of the next year. Annual automatic debits are collected on the first business day of January for $280 for the year (January 1 – December 31).

$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

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.

Authorization

By signing and dating this application, I request the insurance indicated 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.
  • I hereby certify that I am a federal employee and am eligible to enroll under the GEBA sponsored Professional Liability Insurance Policy. I also attest that, as of this date, I have no knowledge of any allegations, claim or suit, or any act, error, or omission which might reasonably be expected to result in a claim or suit.

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.