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Membership
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Resources for Feds
Who We Are

Login Apply Now

Annual Membership Eligibility Questionnaire

Please fill out the form below to advise WAEPA of any such changes that may impact your eligibility for coverage with us.

"*" indicates required fields

Name*

First Name Last Name

Email Address*

Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

MM slash DD slash YYYY

Your Member ID or Certificate Number (Optional)

Must be 6 digits, and include only numbers.

Last 4 Digits of SSN*

Please Answer the Following Questions

I Wish to Update My Contact Information*

Yes

No

New Email Address

New Phone Number

New Mailing Address*

Street Address Address Line 2 City State ZIP Code

My Dependent Child(ren) Have Married*

Yes

No

Date of Dependent Marital Status Change*

MM slash DD slash YYYY

Dependent Name*

Second Dependent Name (optional)

I've Had a Change in Marital Status.*

Yes

No

Marital Status Changes*

Married

Divorced

Widowed

None of the above

Date of Marital Status Change*

MM slash DD slash YYYY

I, My spouse, or My Dependent Child Has Become a Full-Time Member of the Armed Forces* (Excluding National Guard and Reserves)*

Self

Spouse

Child

None of the above

Date of Military Status Change*

MM slash DD slash YYYY

Child's Name*

I Wish to Update My Dependent(s) Contact Information*

Yes

No

Dependent's Name*

First Last

Dependent's Email Address*

Dependent's Phone Number

Dependent's Address*

Street Address Address Line 2 City State ZIP Code

I Wish to Update My Existing Beneficiary's Contact Information*

Please note, this form can only be used to update contact information for existing beneficiaries.
Click here to change your beneficiary designation(s).

Yes

No

Beneficiary Name*

First Last

Beneficiary Email

Beneficiary Phone Number

Beneficiary Address*

Street Address Address Line 2 City State ZIP Code

Second Beneficiary Name (optional)

First Last

Second Beneficiary Email (optional)

Second Beneficiary Phone Number (optional)

Second Beneficiary Address (optional)

Street Address Address Line 2 City State ZIP Code

Contact Us

433 Park Avenue, Falls Church, VA 22046

Hours

M-Th 8:30 a.m. - 6:30 p.m. ET

F 8:30 a.m. - 5:00 p.m. ET

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More Info

© 2024 Worldwide Assurance for Employees of Public Agencies, Inc. All rights reserved.

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Underwritten By

New York Life Insurance Company
51 Madison Ave.
New York, NY 10010

NEW YORK LIFE and the NEW YORK LIFE Box Logo are trademarks of New York Life Insurance Company.

NAIC#66915
On Policy Form GMR
/G-30280-0; G-30281-0

New York Life is domiciled in the state of New York and is licensed/authorized to transact business in all 50 United States, the District of Columbia, Puerto Rico and Canada.

Last revised: 04/09/2024 at 05:29 AM