Form Rethlhen03-I - Retiree Health Benefits Enrollment And Change Form - 2014
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4STATE OF MARYLAND
RETIREE HEALTH BENEFITS ENROLLMENT AND CHANGE FORM
JANUARY 2014-DECEMBER 2014
PERSONAL DATA
PLEASE PRINT CLEARLY
NAME: ___________________________________________________________
SEx:
Male
Female
LAST
FIRST
MI
ADDRESS:__________________________________ APT/CONDO:_________
LEGAL MARITAL STATUS:
Single
Widowed
CITY: ____________________________________________________________
Married
Divorced
Limited Divorce/
STATE: ________________________________ ZIP CODE:_______________
Legal Separation
Home Phone:
( __ __ __) __ __ __ - __ __ __ __
MY STATUS:
Work Phone:
( __ __ __) __ __ __ - __ __ __ __
Maryland State Retirement System Retiree or
Surviving Beneficiary. Please indicate
Cell Phone:
( __ __ __) __ __ __ - __ __ __ __
relationship:__________________________
Optional Retirement Plan (ORP) Retiree
Personal E-mail: __________________________________________
(i.e., TIAA-CREF) or
Surviving Beneficiary. Please indicate
Work E-mail: ____________________________________________
relationship:__________________________
Satellite Retiree
Social Security Number: __ __ __ /__ __ / __ __ __ __
Agency Name:__________________________ or
Surviving Beneficiary. Please indicate
Date of Birth: __ __ /__ __ / __ __ __ __
relationship:__________________________
M M / D D /
Y Y Y Y
STATUS & ENROLLMENT/CHANGE ACTION REQUESTED
Change in Family Status
New Retiree
(See Benefits Guide for documentation requirements)
Request must be made within 60 days of the date of the qualifying event.
Effective Date: ____________
Add Dependent because of:
Last Day of State Employment: ____________
Marriage
Date: ____________
Disability Retirement?
Yes
No
Birth/Adoption/Appointed Permanent Legal Guardian
New Beneficiary of Deceased Retiree
Date: ___________
Name of Deceased: _________________________________
Other Reason: _________________________________________
Remove Dependent because of:
Date of Retiree’s Death: ____________
Divorce/Limited Divorce/Legal Separation Date: ____________
Medicare Eligibility
(Complete Medicare Information Section, page 3)
Death
Date: ____________
(Attach copy of Death Certificate)
Open Enrollment - Effective January 1st
Dependent no longer eligible
Date: ___________
Cancel all Coverage in all Plans/Reason: _________________
Reason: ______________________________________________
___________________________________________________
Other Reason: _______________________________________
COMPLETED AND SIGNED ENROLLMENT FORMS MAY BE MAILED OR HAND-DELIVERED TO:
Employee Benefits Division
EBD Use Only:
301 W. Preston Street, Room 510
____ Reviewed
Baltimore, Maryland 21201
____ Processed
____ Audited
Hours of Operation: Monday - Friday 8:30 a.m. - 4:30 p.m.
Phone: 410-767-4775 or 1-800-307-8283 / Fax: 410-333-5191 / Email: EBD.mail@maryland.gov
Health benefits information and forms are available on the Department of Budget and Management’s website:
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