Insurance Verification Form For Retirement (Page 2 of 2) in pdf

Insurance Verification Form For Retirement Page 2

Attach. 10

________ Initial

(If 2, 3 or 4 are accepted by Council, this statement would appear)

By signing below, I:

i. Understand and accept the terms set forth by the Town for dental and vision insurance

coverage;

ii. Understand that with the years of service listed above with the _______(the State

Retirement System or Town) that I will be required to pay ________% of my premiums

and 100% of the premiums for my spouse and/or dependents for dental and vision

insurance coverage.

iii. Understand that payments are due on the 1

day of each month in advance. Termination

proceedings will commence on the 15

of the month.

iv. Understand that it is my sole responsibility to inform the Town of any dental and vision

insurance coverage changes or cancellation at least 30 days in advance.

______________________

Employee Signature

Date

______________________________

______________________

Human Resources/Finance Director

Date

Insurance Verification Form For Retirement Page 2