Insurance Verification Form For Retirement printable pdf download

Attach. 10

Insurance Verification Form for Retirement

I, ______________________________, hereby give notice that I am retiring on

______________________. Upon my retirement, I will have _____ years of service in the State

Retirement System and _____ years of service with the Town. I meet all qualifications of the

State and Town of Sunset Beach to retire.

Medical Insurance

I understand that my health insurance with the State Health Plan will continue at no charge to me

as my primary insurance until I reach 65 years of age or am deemed Medicare eligible. At that

time, Medicare will become my primary insurance and the State Health Plan secondary. Upon

retirement, I agree to complete an HM form and mail it to the retirement system.

________ Initial

Dental and Vision Insurance

Concerning dental and vision insurance coverage, I understand that:

1. The Town does not offer retirees dental and vision insurance coverage. Coverage will

terminate 30 days after retirement and it will be my responsibility to obtain coverage at

my expense if desired.

2. Employees meeting all State Retirement System and Town qualifications for retirement

may continue to receive dental and vision insurance coverage through the Town at no

cost to the Town. The Retiree will be responsible for 100% of the premiums for

themselves and their dependents.

3. Dental and Vision Insurance

Employees meeting all State Retirement System qualifications for retirement may

continue to receive dental and vision insurance coverage through the Town. Employees

retiring with at least five (5) years of service but less than fifteen (15) years of service

will be required to pay 100% of the coverage cost. Employees retiring with fifteen (15)

years of service but less than twenty-five (25) years of service will be required to pay

50% of the retiree’s coverage cost and 100% of the family/spouse coverage cost.

Employees with twenty-five (25) or more years of service will receive dental and

vision insurance coverage from the Town at no charge and the retiree will be required

to pay 100% of the family/spouse coverage cost.

4. Dental and Vision Insurance

Employees meeting all State Retirement System and Town qualifications for

retirement may continue to receive dental and vision insurance coverage through the

Town. Employees retiring with at least five (5) years of service but less than fifteen

(15) years of service with the Town will be required to pay 100% of the coverage cost.

Employees retiring with fifteen (15) years of service but less than twenty-five (25)

years of service with the Town will be required to pay 50% of the retiree’s coverage

cost and 100% of the family/spouse coverage cost. Employees with twenty-five (25) or

more years of service with the Town will receive dental and vision insurance coverage

from the Town at no charge and the retiree will be required to pay 100% of the

family/spouse coverage cost.

Insurance Verification Form For Retirement