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 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

      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

      Susan Kelley
      Edie Lindsay
      Lee Belaus

      Marketing & Service
      Holmes/Shaw Agency

      Noel Williams