Annuitant Health Care Program Delayed Enrollment Form For Surviving Spouses

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FORM C2
ANNUITANT HEALTH CARE PROGRAM
DELAYED ENROLLMENT FORM FOR SURVIVING SPOUSES
EMPLOYEE / ANNUITANT NAME: __________________________________________
SURVIVING SPOUSE NAME: __________________________________________
SOCIAL SECURITY NUMBER: __________________________________________
•
This is to certify that I am the surviving spouse of a Pennsylvania State System of Higher
Education (State System) employee / annuitant, and am eligible for coverage under the
Annuitant Health Care Program (AHCP).
•
I understand and agree that I have a one-time election to enroll in the AHCP.
•
I am electing to delay enrollment for AHCP coverage at this time due to other health plan
coverage.
•
It is understood that I can exercise my one-time enrollment at a later date upon loss of other
coverage or during an open enrollment period.
________________________________________
__________________________
Signature of Surviving Spouse
Date
Updated 1/28/2015

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