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Committed to the Federal Workforce

Group Term Life Insurance Application $50K Guaranteed

If preferred, download and complete the $50K Guaranteed Coverage Application to return via fax, mail or email.

Fax: (301) 688-6694 | Email: geba@geba.com | Mail: GEBA, P.O. Box 206, Annapolis Junction, MD 20701

General Information

First Name

Middle Initial

Last Name

Gender

Male
Female

Marital Status

Married
Domestic Partner
Divorced
Widow/Widower
Single
Separated

Date of Birth

Email

Home Phone Number

Work Number

Cell Phone Number

Address 1

Address 2

City

State

Zip Code

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.

Type of Member

Hire Date

Indicate the Organization you are with or were last with

How Did You Hear About Us?

Coverage Amount Requested

Guaranteed $50,000. To qualify, you must be 50 or younger.

Replacement Insurance Disclosure and Questions

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assigned, terminated, changed or modified into paid-up insurance or other forms of benefits, loaned against or withdrawn from, reduced in value, by use of cash values or other policy values, changed in length of time or in the amount of insurance that would continue or continued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?

Member

Payment Options

Payment Method

Payment Frequency

Rate ¹

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.

Beneficiary Designation for Member Coverage

Beneficiary Type

Percent of Benefit

Dollar Value of Benefit

Social Security Number

First Name

Initial

Last Name

Relationship

Phone

Date of Birth

Address 1

Address 2

City

State

Zip Code

Beneficiary Type

Percent of Benefit

Dollar Value of Benefit

Social Security Number

First Name

Initial

Last Name

Relationship

Phone

Date of Birth

Address 1

Address 2

City

State

Zip Code

Beneficiary Type

Percent of Benefit

Dollar Value of Benefit

Social Security Number

First Name

Initial

Last Name

Relationship

Phone

Date of Birth

Address 1

Address 2

City

State

Zip Code

Add Another Beneficiary

Fraud Notice

Authorization

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.
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.

Signature (Type in full name)

I Accept

Date

G-29555-1

GMA-GI

50-50-50

P.O. Box 206
Annapolis Junction, MD 20701-0206

Products & Services

Get in Touch

We’re available by phone:
(800) 826-1126
M–F 8:00 a.m.–4:30 p.m. ET.

Connect with GEBA

Securities are offered through Cape Securities, Inc. Member FINRA, SIPC Investment Advisory Services are offered through Cape Investment Advisors, Inc. 1600 Pennsylvania Avenue, McDonough, GA 30253 –
Tel: (678) 583-1120

GEBA Financial Advisors are Registered Representatives of Cape Securities, Inc.

For information about our Wealth Advisors, please visit Broker Check.