| Application
for Employee Enrollment
(must include valid certificate
of prior coverage)
Graphic
Arts Benefit Corporation
6411 Ivy Lane, Suite 700
Greenbelt, MD 20770-1411
Name
of Employer:
Name
of Employee: (last, first, middle initial)
Social
Security No.:
Employee
Address:
Date
Employed: (MM/DD/YY)
Male:
Female:
Single:
Married:
Date
of Birth: (MM/DD/YY)
Occupation:
Weekly
Earnings:
Name
of Beneficiary: (last, first, middle initial)
Relationship
of Beneficiary:
Part
I - dependents to be enrolled
List
spouse and unmarried children to age 23 years. For children over
age 19 years include current, valid student registration or disability
certificate.
Name
of Dependent:
Social
Security No.:
Relationship:
Date
of Birth: (MM/DD/YY)
Name
of Dependent:
Social
Security No.:
Relationship:
Date
of Birth: (MM/DD/YY)
Name
of Dependent:
Social
Security No.:
Relationship:
Date
of Birth: (MM/DD/YY)
Name
of Dependent:
Social
Security No.:
Relationship:
Date
of Birth: (MM/DD/YY)
Name
of Dependent:
Social
Security No.:
Relationship:
Date
of Birth: (MM/DD/YY)
Part
II - other coverage
Are
you or any of the above-listed dependents covered under any other medical
group insurance, student insurance, prepaid Health plan, Medicare of
other government-sponsored plan?
Yes:
No:
If
yes, complete the following:
Insured’s
name:
Group
insurance plan name:
Group
Policy No.:
Certificate
Number:
Insurance
Plan Address:
Telephone
No.:
Don’t
forget to print this form sign & date it and mail to:
Graphic
Arts Benefit Corporation
6411 Ivy Lane, Suite 700
Greenbelt, MD 20770-1411
Date
(MM/DD/YY)
__________________(please
submit this form, print, sign and mail a copy to GABC)
Signature
of employee
_________________________________________________(please
submit this form, print, sign and mail a copy to GABC)
________________________________
998emplapp
Graphic
arts benefit corporation
Please
Click on the SUBMIT BUTTON only ONCE. Your request will be processed.
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