North Dakota Public Employees Retirement System Benefit Election Form printable pdf download

Underwritten by:

NORTH DAKOTA PUBLIC EMPLOYEES

Unum Life Insurance Company of America

RETIREMENT SYSTEM

LTC Department

Benefit Election Form

2211 Congress Street, Portland, Maine 04122

Long Term Care - Policy #510487

Your Name:

Social Security Number

Date of Birth

(Last Name, First, Middle Initial)

(MM/DD/YYYY)

__ __ __ - __ __ - __ __ __ __

__ __/__ __/__ __ __ __

Street Address

Gender

Date of Hire

(MM/DD/YYYY)

Male

Female

__ __/__ __/__ __ __ __

City, State, Zip Code

Home Telephone #

Work Telephone #

(

)

(

)

Complete the following only if applicant is not the employee

Employee's Name

Employee Social Security No.

Employee Date of Birth

Employee Date of Hire

__ __ __ - __ __ - __ __ __ __

__ __/__ __/__ __ __ __

Division

State Central Payroll

All Others

(check one)

Applicant Is:

Employee

Retiree

Employee's Spouse

Retiree’s Spouse

You may choose any of the plans listed below. The Long Term Care Application (medical questionnaire), the Benefit Election

form and a signed Authorization to Request Medical Information Form #6720-03 located in the enrollment kit, must be

completed and you must be approved for coverage in order to enroll in the Long Term Care plan.

Plans

(Check one)

Plan 1A

Plan 2A

Plan 3A

Plan 4A

Nursing Home Facility /

$3,000 Monthly Benefit

Professional Home Care

Total Home Care

Simple Inflation

Total Home Care

Simple Inflation

Plan 1B

Plan 2B

Plan 3B

Plan 4B

Nursing Home Facility /

$3,000 Monthly Benefit

Paid Up Benefit

Professional Home Care

Total Home Care

Simple Inflation

Total Home Care

Simple Inflation

Facility Benefit Duration

(Duration of benefits may vary depending on where benefits are received.)

(Check one)

3 Years

5 Years

Active Employee or Spouse: Your premium will be paid through the Employee’s payroll deduction. Employee must sign below to

authorize the Employer to make the payroll deduction.

Retirees: Please select payment method:

Monthly Automatic Payments (deducted from your checking account – complete

Authorization/Agreement for Automatic Payments), OR

Billed directly (paper) by the insurance company:

Quarterly

Semi-Annually

Annually

Caution: If your answers on this Enrollment Form are incorrect or untrue, we may have the right to deny benefits or rescind

your insurance.

By signing below, you signify that you have read and understand that loss of Activities of Daily Living (ADL) or Severe Cognitive

Impairment must occur after your effective date of coverage under this Long Term Care plan in order to be covered, and that certain

limitations and exclusions apply to your coverage. MA Residents ONLY: You also signify that you have received and read the

MassHealth eligibility notice entitled “For Massachusetts Residents Only”- Form #7650-04. All information is contained in your

kit.

Your Premium: $______________ (Transfer the premium amount from the calculation on the rate sheet)

_______________________

__ __/__ __/__ __ __ __

______________________

__ __/__ __/__ __ __ __

Applicant’s Signature

Date

Employee’s Signature

Date

(Required for Spouse Coverage)

Employees & Spouses: Please sign and mail all required signature forms to your employer.

Retirees: Please sign and mail all required signature forms to Unum (address at top of page).

Retain a copy for your records. (A1)

If you have questions about Long Term Care coverage, please call Unum’s toll-free number: 1-800-227-4165.

Voluntary

North Dakota Public Employees Retirement System Benefit Election Form

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