GBA Insurance Trust Forms

The following insurance forms are available for the use of the GBA members who participate in the GBA Insurance Trust insurance programs.

• GBAIT Request for Change
• GBAIT Death Beneficiary Claim Form
• GBAIT Medical Questionnaire (Late Enrollee for Dependent Life Insurance)
• GBAIT Evidence of Insurability (Late Enrollee for Long Term Disability Insurance)
• Leave of Absence Form
• Long-Term Disability Claim Form
• GBAIT Notice of Employee Termination
• GBAIT Notice of Privacy Practices
• Full Time Enrollment Card
• Part Time Enrollment Card

Please email completed forms to Jayn Lawson and Lauran Dunn.

Prescription Drug Forms

The following should sent per instructions on the forms.

• Optum Mail Order Form
• Prescription Drug Direct Member Reimbursement Order Form
• Prior Authorization Form

Need assistance?

Contact the GBA Insurance Trust Staff.