UUA Health Insurance Enrollment Application Logo
  • UUA Insurance Plans Benefit Enrollment Application

  •  Please review and gather the required information for the Enrollment Process:

     

    You will see a red star reminder (*) next to fields that need to be entered or have been entered incorrectly.

    Your Social Security Number is encrypted; all information is confidential and stored in a secure location.

    You will receive an email confirmation when you finish your application.

    To add a dependent to your existing coverage please use this form

    If you have any questions please contact Insurance Plans at (888)792-7496 or InsurancePlans@uua.org

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  • To begin the enrollment process please enter an identifier in the box below: Your 4-digit congregation ID or association ID. (Select ID Here.)

    For community ministers and retirees, enter SELF.

    If you do not see your congregation or association ID code on the list, please contact Insurance Plans at (888) 792-7496 or insuranceplans@uua.org for the correct code.

  • Section One

    UUA Insurance Plans
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  • Guardian Group Insurance Plan Enrollment Form

  • Section Two

    Demographic Information
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  • Section Three

    Employment Information
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  • Authorizing Church Leader or Administrator

    (the officer, administrator, or other person certifying your employment and hours worked)
  • Dependent Demographics

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  • Clear
  • Should be Empty: