Form Retef15 - Retiree Health Benefits Enrollment And Change Form - 2016 Page 4
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4ENROLLMENT FOR JANUARY 2016-DECEMBER 2016
Life Insurance
Retirees cannot have a break in Life Insurance coverage between employment and retirement, increase the amount of coverage
or add new dependents upon or after retirement. Retirees (new or existing) may only continue, decrease or cancel Life Insurance for
themselves and their eligible dependents who are enrolled in Life Insurance at the time of retirement. If you choose to decrease or cancel
coverage, you cannot re-enroll or increase coverage in the future. Surviving Beneficiaries who were enrolled in Dependent Life Insurance
under the deceased Retiree may only continue Life Insurance through a conversion policy purchased directly from the plan.
RETIREE
Choose One Option:
Choose a coverage amount in increments of $10,000 for yourself
(must be equal to or less than current coverage):
Continue Life Insurance
Fill in the amount of Benefit
Decrease Life Insurance
,
$
0
0 0 0
Cancel Life Insurance
SPOUSE
Choose One Option:
Choose a coverage amount in increments of $5,000 for your spouse up
to 1/2 of the amount chosen for yourself (must be equal to or less than
Continue Spouse Life Insurance
current coverage):
Fill in the amount of Benefit
Decrease Spouse Life Insurance
$
,
0 0 0
Cancel Spouse Life Insurance
CHILDREN
Choose One Option:
Choose a coverage amount in increments of $5,000 for your and/or
your spouse’s children up to 1/2 of the amount chosen for yourself
Continue Child Life Insurance benefits
(must be equal to or less than current coverage):
Decrease Child Life Insurance benefits
Fill in the amount of Benefit
$
,
0 0 0
Cancel Child Life Insurance benefits
NOTE: See Benefit Guide for information about automatic reductions in Life Insurance coverage beginning at age 65.
Retiree Signature
Please enroll me for the benefits indicated on this form. I understand the benefits and limitations provided by the various plans and I
authorize the State of Maryland to make the necessary adjustments in my retirement allowance based on the choices I have made. I agree
to make any premium payments necessary if my retirement allowance will not support the necessary deductions. I understand that to
the extent the State subsidizes or pays part of the cost of my coverages, there may be tax consequences to me if I cover dependents who
are not my tax dependents. To the extent deemed necessary by the Plan Administrator for the proper administration of my coverages, I
authorize the release of all medical records and related information pertaining to me or my dependents to the benefit plans. The personal
information provided on this enrollment form is complete, accurate, and in accordance with the Department of Budget and Management
regulations. The Mandatory Insurer Reporting Law 42 U.S.C. 1395y(b)(7) requires group health plans to report SSNs in order for
Medicare to coordinate payments with other insurance benefits. Please refer to our Notice of Privacy Practices in the Benefit Guide and
on our website for more detailed information. I understand that I cannot cancel or change my enrollment except during an Open
Enrollment period or as a result of a qualifying event in accordance with COMAR 17.04.13.04 and IRS Section 125.
I understand that the Benefit Program offered by the State is subject to modifications and changes and that the benefits I have chosen in
this enrollment are only in effect for the current plan year. The State of Maryland reserves the right to modify any of the benefits provided
and gives no assurances, expressed or implied, that any coverage obtained hereunder will continue beyond the end of the current plan year.
I certify that I and any dependents listed for coverage are eligible for coverage. I understand that enrollment in benefits to which I or
my dependents are not entitled is considered fraud. In all cases I am responsible for the accuracy of my benefits, coverage levels and
deductions. I further understand that if I willfully misrepresent the eligibility of myself or my dependents on my benefits application, or
fail to take the necessary action to remove ineligible dependents, or in any way obtain benefits to which I am not entitled, my benefits will
be cancelled. I may be required to repay any claims and insurance premiums which have been paid inappropriately and may face criminal
investigation and prosecution.
I certify that neither I nor my covered dependents are covered under another State of Maryland employee’s or retiree’s
membership for any coverage for which I or they are enrolled on this form.
I further solemnly affirm under the penalties of perjury under applicable state laws that any dependent information I have provided is
true and accurate. I understand that willful falsification of information contained in this attestation can result in referral of the matter for
investigation and prosecution, the termination of enrollment and coverage of the person identified as my dependent, and the termination of
coverage for myself (the retiree). I understand that a civil action may be brought against me for any losses, including reasonable attorney
fees because of a false statement contained in this attestation, and that other serious consequences may result.
I further attest and agree that if a dependent’s status changes and the dependent is no longer eligible, I will notify my Agency Benefit
Coordinator or the Employee Benefits Division immediately to remove this dependent from my coverage. I also agree to provide the
required documentation as outline in the current plan year’s Benefits Guide to substantiate the information I have provided, and affirm that
each enrolled dependent is my true tax dependent.
X __________________________________________________
_____/______/_______
Retiree/Beneficiary Signature
Date
If you have any questions concerning the benefits and services that are provided by or excluded under this agreement, please contact the plan’s
member service department before signing this application. Plan phone numbers are listed on the inside front cover of the Benefits Guide.
RETEF15
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