New Retiree Health Benefits Election Form - Pleasant Valley School printable pdf download

PLEASANT VALLEY SCHOOL DISTRICT

NEW RETIREE HEALTH BENEFITS ELECTION FORM

Your current PVSD health benefits coverage will end the last day of the month of your last regular work

day at PVSD. To continue coverage, you must submit this form and the applicable enclosed form(s) to the

PVSD Employee Benefits Specialist no later than 30 days from the last day of your current coverage. PVSD

will complete the form, return a copy to you, and invoice you for premiums exceeding your benefit cap (if any).

You must also send a copy of your 1

STRS or PERS retirement check no later than 60 days after retirement.

If continuing medical coverage, you will receive a new card with a retiree group number. To decline

continuation of all coverage, check the box below, sign and date this form and return it to the PVSD Employee

Benefits Specialist within 30 days from the date your current coverage ends.

Name_______________________________________

Address____________________________________________

Social Security #: Last 4 Digits Only: __ __ __ __

City_______________________________________________

Home Phone # (

) __________________________

State_________________________ Zip Code_____________

Last Regular Work Day ______________________

I elect to: Continue Coverage ( ) Decline All Coverage ( )

TO CONTINUE COVERAGE, list yourself and all currently enrolled dependents. Indicate if you elect to

delete or continue current coverage

. If no current coverage, leave the box blank. If you delete coverage for yourself

or your dependents, you cannot add it later. (Note: you cannot add coverage you aren’t enrolled in at retirement.)

COVERAGE

BIRTH DATE

D=DELETE

√ = CONTINUE

RELATIONSHIP

LAST NAME

FIRST

INITIAL

MM/DD/YYYY

MED

DEN

VIS

SELF

MEDICAL PLAN CHANGE (i.e., from Kaiser to Blue Cross) is permitted within 30 days of PVSD retirement

(or at Open Enrollment). If you wish to change plans now, indicate the new plan:________________________.

Signature _______________________________ Date _____________________

SEE THE PVSD RETIREE HEALTH BENEFITS INFORMATION SHEET

**************************DO NOT WRITE BELOW THIS LINE: FOR BENEFITS OFFICE USE ONLY*************************

HEALTH NET( ) KAISER( ) SISC80G( ) SISC90D( ) SISCHDHP( ) CCARE ( ) 1P( ) 2P( ) Fam( ); Under 65( ) MCare

Supp( ); Basic/MCare Supp( ); Other:_____________________; DENTAL 1P( ) 2P( ) Fam( ); VISION 1P( ) 2P( ) Fam( )

Classified ( ) Certificated ( ) FY Cap: None( ) $3,900( ) $2,400( ) $0( ) Other:______ Lifetime ( ) To Medicare ( )

Total FY Premiums:

$__________

_______to_______

Medical $_________

$_________

District Pays Others* $ _________

Medical* $_________

$_________

Retiree Cap

- __________

Dental*

_________

District Pays Retiree $__________

Vision*

_________

Retiree Pays District $__________

Subtotal $_________/mo

$_________/mo

7/1/___ to 9/30/___

$_______/mo

mos

10/1/___ to 6/30___ $_______/mo.

TOTAL $ _________

$ _________

Inv. #_________________________

Rec._____________ By__________ Payroll HW________ PY_________ Medical_______ Dental________ Vision_______ Ret Copy______

T:\Kennaley\Health Benefits\Retirees\Retiree Enrollment Form.doc

5/31/05 Rev. 2/12/09

New Retiree Health Benefits Election Form - Pleasant Valley School

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