Form 6256 - Designation Of Spouse And/or Dependent Child For Health Insurance
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2Kentucky Retirement Systems
Perimeter Park West
1260 Louisville Rd.
Frankfort KY 40601-6124
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Phone: (502) 696-8800
Fax: (502) 696-8822
kyret.ky.gov
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Form 6256
Print Form
Revised 9/2015
Designation of Spouse and/or Dependent Child for Health Insurance
Complete this form if you are a General Assembly Retiree, Hazardous Duty Retiree, Surviving Spouse Beneficiary receiving
General Assembly, Hazardous Duty, or duty related benefits under the Fred Capps Memorial Act and electing to cover a spouse
and/or dependent child on health insurance.
Member Information Please provide your Member ID or Social Security Number in the Member ID box below
Recipient Name:
Recipient ID:
Address:
City:
State:
Zip Code:
Phone Number:
Yes
No
Is this a new address?
If you are beneficiary to the account please provide the member's name and Member ID below
Member Name:
Member ID:
Spouse Information
Spouse
Social Security
Spouse
Name:
Number:
Date of Birth:
Address:
City:
State:
Zip Code:
Dependent Information
Dependent
Social Security
Dependent
Name:
Number:
Date of Birth:
Address:
City:
State:
Zip Code:
Relationship to Member:
Natural Child
Adopted Child
Is this dependent married or has this dependent been married previously?
Yes
No
Is this dependent age 18 or older?
Yes
No
Is this dependent a full time student?
Yes
No
Dependent Information
Dependent
Social Security
Dependent
Name:
Number:
Date of Birth:
Address:
City:
State:
Zip Code:
Relationship to Member:
Natural Child
Adopted Child
Is this dependent married or has this dependent been married previously?
Yes
No
Is this dependent age 18 or older?
Yes
No
Is this dependent a full time student?
Yes
No
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