Fillable Form 20-487b - Retirement Plan Election printable pdf download

RETIREMENT PLAN ELECTION FORM

(For employees hired/eligible on or after Aug. 1, 2005)

You will have 120 days from the starting date of your employment to complete and return this election form to the Human Resources Department at your

institution. If you want to become a member of an Ohio state retirement system, simply check the appropriate box in Section 2 below. If you want to participate in an

alternative retirement plan (ARP) offered by a private plan provider, check the appropriate box in Section 2 below and select one of the plans. If you do not elect to

participate in an ARP or do not return this form within the prescribed time period, you will be enrolled in the applicable state retirement system.

Section 1 — Biographical Information (Please print or type.)

Name ___________________________________________________________

Social Security no.

______________________________________

First

Middle initial

Last

(

)

Address __________________________________________________________

Phone number

__________________________________________

Birth date _________________________ Gender _________

___________________________________________________________________________

City

State

ZIP code

Employee identification number _______________________________________

Hire date __________________________________________

If applicable

Are you receiving a retirement benefit from one of these Ohio retirement systems: HPRS, OPERS, OP&F, SERS or STRS Ohio?

❏

Yes

❏

If “Yes,” which system? _____________________________________________

Effective date of retirement ___________________________

Section 2 — Election (Choose only one.)

❏

I elect to participate in an ARP: (Select only one of the following ARP carriers. You must

I elect to participate in the

state retirement system for

contact your chosen carrier to enroll.)

which I am eligible.

❏

AIG VALIC

❏

Lincoln National Life Insurance Co.

• OPERS*

❏

AIG SunAmerica Life Assurance Co.

Metropolitan Life Insurance Co.

• SERS

❏

AXA Equitable Life Insurance Co.

❏

Nationwide Life Insurance Co.

• STRS Ohio*

❏

Fidelity Investments

❏

TIAA-CREF

I understand that I may not change my election to

participate in the state retirement system after my

❏

Great American Life Insurance Co.

❏

The Hartford

election period expires and that my election will be

irrevocable while I am continuously employed in a

❏

Voya Financial

❏

The Travelers Companies, Inc.

position at my current college or university.

I understand that by electing to participate in an ARP I am irrevocably waiving my right to participate

in the eligible state retirement system while I am continuously employed in a position at my college or

*Eligible employees may be able to participate in a defined

university. I also understand that by electing to participate in an ARP offered by a private plan provider,

contribution plan. Contact your applicable retirement system for

I will be forever barred from claiming or purchasing service credit or participating in other plans offered

more information about these plans and eligibility.

by any state retirement system for the period that an election to participate in an ARP is effective.

Section 3 — Authorization

I hereby certify the election chosen above in Section 2. I understand that I will be able to make an election to participate in another ARP or Ohio public

retirement system if I cease to be continuously employed or am subsequently employed full time by another Ohio public institution of higher education

in a position for which a retirement election is available.

______________________________________________________________________________________

_______________________

Employee’s signature

Date

OFFICE OF HUMAN RESOURCES USE ONLY

❏

Applicable state system

OPERS

SERS

STRS Ohio