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
• CVS/Caremark Mail Order Form
• Direct Member Reimbursement Form
• Prior Authorization Form

New Enrollment Cards

• Full-time
• Part-time

Please mail all completed forms to the attention of Lee Belaus at:

GBA Insurance Trust
50 Hurt Plaza, Suite 1050
Atlanta, Georgia 3030

Contact GBA Insurance Trust Staff

Tripp Cofield
Lee Monroe
Jayn Lawson
Keri Brooks
Tessa Nolan

Contact Marketing & Service
The Holmes/Shaw Agency

Bruce Shaw
David Holmes
Rad Downey
Skip Hill
Guy Whidby
Noel Williams
Taylor Smith