Notice in Change in Enrollment

Change in Enrollment

Graphic Arts Benefit Corporation
6411 Ivy Lane, Suite 700
Greenbelt, MD 20770-1411

Enter your new address in the space below and submit this form to GABC so we can begin processing the change. You will need to print a hard copy, sign/date it and mail or fax it to us for verification. It'll help us to serve you better.

Name of Employer:

Employee Name:

Social Security No:

Add Dependents:

Effective Date:

Reason:

Marriage (date):
Birth (date):
Loss of Coverage (date):
Individuals enrolling dependents as a result of marriage or for loss of coverage must include valid CERTIFICATE OF PRIOR COVERAGE with enrollment.

Part I - Dependents to be enrolled. List spouse and unmarried children to age of 23 years. For children over age 19 years, include current valid student registration or disability certificate.

Name of Dependent:

Social Security Number:

Relationship:

Date of Birth:

Delete Dependents:

Effective Date:

Delete All Dependents?: Yes No
If no, list all dependants to be covered.

Name of Dependent:

Social Security Number:

Relationship:

Date of Birth:

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, or other government sponsored plan?
Yes No
If yes, complete the following.

Insured’s name:

Group Insurance Plan Name:

Group Policy Number:

Certificate Number:

Insurance Plan Address:

Telephone Number:

Signed:

Dated:

Please Click on the SUBMIT BUTTON only ONCE. Your request will be processed.

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