Enrollment Form
Long Term Disability Coverage
 
 
A. Agent/Staff Information
Last Name
First Name
M.I.
Group Name
Boulder Valley IPA
Policy Number : 144460
Social Security Number
         - -   
Date of birth (mm/dd/yyyy)
            - -
BVIPA Membership Start Date (mm/dd/yyyy)
    / /
Sex (M/F)
     M         F
Work Mailing Address
City
State
Zip Code
Work Phone Number
         - -   
Hours Worked Per Week
Are you a Member/Physician or a Staff member?
Member/Physician    Staff
  Work Email Address
Annual Income: $
(Not monthly, annual amount only)
B. Monthly Premium Calculation
  Enroll 
1. Long Term Disability: =$
Total Monthly Cost: =$  
D. Signature

I understand that by signing this form I am authorizing the necessary premium deductions via EFT from a designated account.
I will click “Print” below and fax both this completed, signed and dated form and a copy of a voided check (for premium deductions) to 832-202-2686.
I will complete section E. and click “Submit” below to electronically submit my enrollment and payment information.

E. Payment Information
I authorize the payment of benefit premium through the monthly direct debit from the authorized checking account listed below.
         (Enter your account debit information below (this site secured by SSL for your protection)
Routing Number.(This is the nine digit number in the lower left hand corner of your check)
   See an example
    Account Number
  
  Name on Account
  
F. Administrative Use Only
Application within eligibility period
Late applicant
Applied during open enrollment
Member Effective Date (mm/dd/yyyy)

         - -
            
 

Signed for Association By:
 
Click "Submit" below to electronically send your enrollment and payment information to MGC Group. You may also click the “Print” button to print a copy of this form for your records.

Submit Form and Print a copy for my records    

 
 

   Get more information at www.bvipabenefits.com.
Questions? Call 816-753-7372 or Email info@mgcfirst.com