GBA Insurance Trust Forms

Thee 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 HMO/POS Change Form
• 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
• Mail-Order Prescriptions
• GBAIT Notice of Employee Termination
• GBAIT Notice of Privacy Practices

New Enrollment Cards

• Full-time
• Part-time

Please mail all completed forms to the attention of Susan Kelley at:

GBA Insurance Trust
50 Hurt Plaza, Suite 1050
Atlanta, Georgia 30303

Contact GBA Insurance Trust Staff

Contact Marketing & Service
Holmes/Shaw Agency