Enrollment Questionnaire

Please complete and submit this Enrollment Questionnaire to help speed up access to your benefits.

This checklist will help you be prepared to answer all of the questions on the form.

If you need assistance, please contact us

This information is being submitted via a secured connection. Please see our privacy policy for more information.

Member Information

Please enter the 8-digit GEHA ID number located on your ID card.
If you commonly use a name other than your first name, please enter that here.
Are you married?

Primary Contact Information

Would you like to provide an alternate address (for a summer home for example)?

Plan Information

In which plan are you enrolling?

Who is enrolling in the plan?

Other FEHB Coverage Information

Are you or any covered dependent enrolled in another Federal Employees Health Benefits (FEHB) plan?

Other Non-Federal Coverage Information

If you or a dependent have any other coverage with which GEHA will need to coordinate benefits, please answer yes and enter the requested information.

Are you or any covered dependent enrolled in any other non-federal health insurance plan?

Workers Compensation Information

Have you or any covered dependent filed a claim with Workers' Compensation?

Medicare Information

Are you or any covered dependents enrolled in Medicare?

By entering the name below, I certify the information furnished by me is true and correct to the best of my knowledge and belief.