Employer Verification Of Insurance Coverage
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153621
EMPLOYER VERIFICATION OF INSURANCE COVERAGE
NORTH DAKOTA PUBLIC EMPLOYEES RETIREMENT SYSTEM
SFN 53621 (Rev. 06-2015)
NDPERS • PO Box 1657 • Bismarck • North Dakota 58502-1657
(701) 328-3900 • 1-800-803-7377 • Fax 701-328-3920
Instructions:
Please complete Part A and B information and forward the form to the former employer to verify coverage in Parts C,
D, E, and to sign Part F. These Parts must be completed by an authorized staff employee of the employer. This information is used to
determine eligibility for insurance provided through the North Dakota Public Employees Retirement System (NDPERS). This
information must be returned to NDPERS accompanied by the applicable enrollment form(s).
PART A
NDPERS MEMBER INFORMATION
NDPERS Member Name (Last, First, Middle)
NDPERS Member ID (If applicable)
PART B
EMPLOYEE AND EMPLOYER INFORMATION
Employee Name (Last, First, Middle)
Employer Name
Date Employment Terminated
PART C
HEALTH INFORMATION
Month and Year the Employee is Covered on Employer Group Insurance Billing: From:____/____/____
Through:___/____/____
Does employee currently participate in the employer sponsored HEALTH plan?
No
Yes, Current level of coverage: __________________
Has employee been covered under COBRA?
No
Yes, If yes, Beginning date of COBRA: ____/ ____/ ____
Ending date of Health Coverage: ____/ ____/ ____
PART D
DENTAL INFORMATION
Last Month and Year the Employee is Covered on Employer Group Insurance Billing: ____/ _______
Does employee currently participate in the employer sponsored DENTAL plan?
No
Yes, Current level of coverage: _____________________
Has employee been covered under COBRA?
No
Yes, If yes, Beginning date of COBRA: ____/ ____/ ____
Ending date of Dental Coverage: ____/ ____/ ____
PART E
VISION INSURANCE
Last Month and Year the Employee is Covered on Employer Group Insurance Billing: ____/ _______
Does employee currently participate in the employer sponsored VISION plan?
No
Yes, Current level of coverage: ______________________
Has employee been covered under COBRA?
No
Yes, If yes, Beginning date of COBRA: ____/ ____/ ____
Ending date of Vision Coverage: ____/ ____/ ____
PART F
EMPLOYER CERTIFICATION
Signature of Authorized Personnel
Date of Signature
Telephone Number:
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