Retiree Benefit Election Form Under 65 printable pdf download

UNM PRE-65 BENEFIT ELECTION FORM

UNM Retiree Information

Name (Last, First, MI) PLEASE PRINT

BANNER ID

Date of Birth

Effective Date of Retirement

IMPORTANT: PLEASE READ: I have contributed to UNM’s Voluntary Employee Beneficiary Association (VEBA) and am

eligible to retire under the New Mexico Education Retirement Act (ERA) plan or the Alternative Retirement Plan (ARP). Based on

this, I elect to make the following benefit changes upon retirement. I understand that I will be billed by the UNM Bursars Office on

a monthly basis and agree to make my payments IN FULL each month. I further understand that failure to do so CAN result in

cancellation of my UNM post-retirement benefits.

Signature___________________________________________________________Date:_________________________

Health Insurance Plan Election



I am electing to CONTINUE the same medical coverage I currently have for myself and any enrolled dependents. If any of my

dependents are 65 or over or Medicare-eligible, I understand that they will need to enroll in a UNM-sponsored Medicare plan at the

time of my retirement.



I have not previously been enrolled in UNM medical benefits. I am electing to ENROLL in the following UNM medical plan:



Presbyterian-retiree only

Presbyterian-retiree and dependent(s)



BlueCross BlueShield -retiree only

BlueCross BlueShield-retiree and dependent(s)



UNM Health-retiree only

UNM Health

retiree and dependent(s)



I have been covered under another UNM employee and would like to ENROLL IN / CANCEL (circle one) post-retirement medical

benefits upon retirement. The UNM employee’s information is as follows:

NAME _________________________________________________________BANNER ID__________________________



I am electing to CANCEL my health insurance coverage with UNM. I understand that once I cancel my coverage I cannot re-enroll at

a later date.

Dental Insurance Plan Election



I am electing to CONTINUE the same dental coverage I currently have for myself and any enrolled dependents, if applicable.



I have not previously been enrolled in UNM Dental benefits. I am electing to ENROLL in the following UNM Dental plan:



Delta Dental High Option-retiree only

Delta Dental High Option-retiree and dependent(s)



Delta Dental Low Option-retiree only

Delta Dental Low Option-retiree and dependent(s)



I have been covered under another UNM employee and would like to ENROLL IN / CANCEL (circle one) post-retirement dental

benefits upon retirement. The UNM employee’s information is as follows:

NAME _______________________________________________________BANNER ID_____________________________



I am electing to CANCEL my dental insurance coverage with UNM. I understand that once I cancel my coverage I cannot re-enroll at

a later date.

Basic and Supplemental Life Insurance Elections



BASIC LIFE: I am electing to CONTINUE / CANCEL (circle one) my Basic Life insurance



BASIC LIFE: I DO NOT have Basic Life insurance, but plan to apply for coverage directly with the Life Insurance provider. If I am

approved, I will provide UNM Human Resources with a Certificate of Coverage from the carrier at the time of approval.



SUPPLEMENTAL LIFE: I am electing to CONTINUE / CANCEL (circle one) my Supplemental Life insurance at the following level:



Tier 1

Tier 2

Tier 3

Tier 4 or 5 (if approved and enrolled prior to retirement date



SUPPLEMENTAL LIFE: I DO NOT have Supplemental Life insurance beyond the Basic level

Retiree Benefit Election Form Under 65

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