Enrollment/change Form - Vermont Retirement Division
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1
2ENROLLMENT/CHANGE FORM
RETIREE MEDICAL
___
RETIREE INFORMATION
Return all completed forms to:
STATE OF VERMONT
Name:
Retiree ID:
RETIREMENT DIVISION
109 STATE STREET
Date of Birth:
___
SSN:
MONTPELIER, VT 05609-6901
Home Phone:
___
Work Phone:
Street Address: _______________________________ City, State, Zip:__________________________________
ACTION REQUEST
New Hire
Open Enrollment
Remove/Add Dependent
Cancel Coverage
If Add/Remove, please give reason and effective date (i.e. Birth, Death, Marriage, Divorce and Date)
STATUS
Single
Married*
Domestic Partner
Widowed
Divorced
Dissolution Domestic Partnership or
Civil Union
I
f status has changed, please provide date of event __________
BENEFITS
#1. CHOOSE MEDICAL PLAN
#2. CHOOSE COVERAGE
I select the MEDICAL
SelectCare POS
Employee Only
coverage to the RIGHT
TotalChoice
Two Person
Family
(Complete 1, & 2 plus the
Dependent section below)
(Employee + 2 or more)
Either myself, my spouse, or (one of) my dependents is eligible for Medicare Part A and/or Part B
PLEASE PROVIDE ALL REQUESTED INFORMATION BELOW AND SIGN THE NEXT PAGE
YOU & DEPENDENTS
RELATIONSHIP CODES: Spouse = SP; Child = CH; Domestic or Civil Union Partner = NQP
-
Fill in your own information on the first line. Your dependents include your spouse, civil union partner, qualified
domestic partner, unmarried children under age 26, including children of your civil union or qualified domestic
partner.
Coverage Election
Person Has Other
Medical
Medicare-eligible
Insurance
Employee Coverage
Y
N
Y
N
Y
N
Coverage Election
Person Has Other
Medical
Medicare-eligible
Insurance
Name: ________________
Y
N
Y
N
Y
N
Relationship: ____________
Date of Birth: __________
Male
Female
SSN:
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