Application for the Retired/Disabled Health and Dental Insurance Group

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Application for the Retired/Disabled Health and Dental Insurance Group \\\data\hreusers\jpierso\documents\my pictures\das_logo.jpg

1. Name and Home (billing) Address:

2. Home Email Address (required if you have one)




(Email with any change in your email address.)


3. Last Four of Social Security Number      ___________________


4. Date of Birth      _________________

5. Have you applied for IPERS or LTD benefits?  Yes  No


Effective Date.______________________

Health Code ___________________________

Dental Code ___________________________

6. Date of Retirement      ____________________ OR Long-Term Disability (LTD) Benefit Effective Date      ___________________
I understand that I have 30 days from the effective date of my retirement or approval for LTD benefits to elect or waive health and/or dental insurance.

I elect

 Wellmark Health Insurance Plan      _____________________________ Coverage: Single  Family 

 Delta Dental Insurance Plan and Coverage  Single  Family

You must complete new health insurance application and/or dental application.

Waive Coverage

 I waive health coverage in the Retired/Disabled Group.

 I waive dental coverage in the Retired/Disabled Group.

I understand and accept that it is necessary and required, in order for health insurance claims to be paid properly, that when I, or my spouse/dependents, if covered under my health plan, become eligible for Medicare, the Medicare eligible person must enroll in both Parts A and B of Medicare. It is my responsibility to notify Wellmark of my or my spouse/dependent’s Medicare eligibility.

Please sign and retain a copy of this form for your records.
______________________________________________________________________ _______________

Signature Date


  • You will receive a bill, if applicable, from your Wellmark and/or Delta Dental insurance carrier for the next premium payment.

  • You may sign up for automatic account withdrawal from your checking or saving account. Contact the insurance carrier for details.

  • If retiring, individuals 55 years of age and older must be eligible for and must have made application for IPERS benefits.

  • Individuals 65 years of age and older who are applying for continuation in the health insurance program must have applied for Medicare and completed the insurance application for change to “Medicare Carve-Out” coverage. A copy of the Medicare card or a letter from the Social Security Administration showing Medicare A & B effective dates MUST accompany this paperwork.

Return this form, and a copy of the insurance application(s), to your department’s Human Resources Associate.

Reason for Continuation:

 Retirement  Sick Leave Insurance Program

State Share: $

Retiree Share: $

TOTAL: $____________

 Long-Term Disability (LTD) Effective Datel

 Resigning General Assembly Member

Active health and dental coverage ends      __________________

HRA contact:      ________________________________________

HRA phone number:      ______________________

CFN 552-0442 R 09/16

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