Form 60036 - Health Insurance Application Or Change
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60036
HEALTH INSURANCE APPLICATION OR CHANGE
NORTH DAKOTA PUBLIC EMPLOYEES RETIREMENT SYSTEM
SFN 60036 (Rev. 03-2016)
NDPERS PO Box 1657 Bismarck North Dakota 58502-1657
(701) 328- 3900 1-800-803-7377 Fax 701-328-3920
PART A
MEMBER IDENTIFICATION
Employee Name (Last, First, Middle)
NDPERS Member ID
Last Four Digits of Social Security Number
Date of Birth
Daytime Telephone Number
Organization Name
NDPERS Organization ID
Active in the Military?
No
Yes
PART B
INSURANCE ELECTION
Effective Date of Change (MM-DD-YYYY):
Section 1
Change Reason:
New Coverage
Loss of Other Coverage
(I do not have existing coverage)
Annual Enrollment
Transfer Employment:
ACA Temporary
from___________________ to _____________________
(Employer Complete Part F)
Cancel Coverage
Transfer from existing policy
(Complete Part E)
Remove Dependent
Add Dependent:
Is this an adult child?
No
Yes. Please answer the following questions.
Is adult child Disabled?
No
Yes
Section 2
Type of Coverage:
PPO/Basic Health Plan
High Deductible Health Plan/Health Savings
Account (HDHP/HSA) This option is available only to
PPO/Basic Health Plan Authorization: By signing
permanent employees of state agencies, the university
this application I represent that I am joining the
system, and district health units.
PPO/Basic Health Plan. I acknowledge I have had the
opportunity to review the terms and conditions relating
HDHP/HSA Authorization: By signing this application
to participation in the PPO/Basic Health Plan.
I represent that: (1) I am joining a HDHP/HSA; (2) I will
not be covered by any other health plan that is not a
HDHP (including my spouse’s general-purpose health
care Flexible Spending Account, which is a non-HDHP)
for the upcoming plan year or enrolled in Medicare; I
________________________________________
have not enrolled in my employers general-purpose
Member’s Signature
health care Flexible Spending Account for the
upcoming plan year and (3) I cannot be claimed as a
________________________________________
dependent on another person’s tax return. I understand
Date of Signature
that a HSA will be established on my behalf. I
acknowledge I have had an opportunity to review the
terms and conditions relating to participation in the
HDHP/HSA.
________________________________________
Member’s Signature
________________________________________
Date of Signature
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