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.
Eligibility is determined by state law.
We (Member Name) and
for the purposes of establishing Domestic Partner status under the voluntary employee benefits organization, Government Employees' Benefit Association (GEBA) and Government Employees' Mutual Benefit Association (GEMBA), attest and agree as follows:
We have provided the information in this Declaration of Domestic Partnership to GEBA for the sole purpose of establishing eligibliity as Domestic Partners.
We hereby affirm that the assertions in this statement are true to the best of our knowledge.
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.
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.
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.
Your Vision Insurance will be effective the first of the following month unless you specified a future month for your coverage to begin.
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.
By signing above, I agree to pay a full year of premium payments. I understand that if I cancel coverage before paying for a full year of premium payments, the balance will be due at the time of cancellation. Rates are based on 100% member contributions.
To view your rate, you must enter your plan, coverage and the payment frequency.