Uniformed Services Benefit Association  

Active Duty Air Force or Navy: Start a New Allotment Deduction

Print and fill out this form, then take to your Finance Officer.

Name (Please Print):
Social Security Number:

Please START my allotment as outlined below:


Uniformed Services Benefit Association
PO Box 25956
Overland Park, KS 66225-0956

 Allotment Start Amount:
(Exact Amount of your USBA Premium)

Effective Date: IMMEDIATELY
Reason: Insurance Premium
Group Policy Number: Use SSN
Blanket Company Code: N160304
Date Signed: