Teacher Retiree Over 65 Medical Form - Office Of The State Treasurer
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1
2Vermont State Teachers’ Retirement System
Medicare Supplement
Application and Change Form
All information must be provided.
Please print in ink or type.
Send to Vermont State Teachers’ Retirement System • 109 State Street 4th Floor • Montpelier, VT 05609-6901
Section 1: Product
c Vermont Blue 65
c Comp carve out
c J carve out
Section 2: Group Information
Group Name
Vermont State Teachers’ Retirement
Group No. (including section)
8 0 7 2 4 __ __ __
Section 3: Subscriber Coverage Information (for all transactions)
Name
Social Security No.
Date of Birth
Last Name
First Name
M.I.
Home Phone No.
Gender c Male c Female
Physical Address
Mailing Address
Street Address
Street Address
City
State
ZIP Code
City
State
ZIP Code
A Photocopy of Your Medicare Card Must Be Enclosed
Marital Status
c Single
c Married/Party to a Civil Union
Section 4: Reason for Form (check applicable boxes and indicate dates as mm/dd/yyyy)
Application
Reason for Change
Cancellation
c Full Time Hire/Rehire
c Voluntary Cancel
c Change of Address
c Transfer from other BCBS Plan
c Obtained Other Coverage
c Change of Name
c Turned 65
c Retired-transfer to Non-group Coverage
c Other
c Death
Effective
Date:___/___/_____
Date of
Change:___/___/_____
Date of
Cancellation:___/___/_____
Section 5: Questions
(1) To the best of your knowledge, do you have another Medicare supplement policy or certificate in force (including health care service contract or health
maintenance organization (HMO) contract)? If yes, with which company?
c Yes
c No
Insurance Company (name and address)
Policy Holder Name
Policy No.
Group No.
Effective Date
(2) To the best of your knowledge, do you have any other health insurance policies that provide benefits which this Medicare supplement policy would
duplicate? If yes, with which company?
c Yes
c No
Insurance Company (name and address)
Policy Holder Name
Policy No.
Group No.
Effective Date
280.285 (08/2014)
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