Enrollment/change Form - Vermont Retirement Division Page 2
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1
2Coverage Election
Person Has Other
Medical
Medicare-eligible
Insurance
Name: ________________
Y
N
Y
N
Y
N
Relationship: ____________
Date of Birth: __________
Male
Female
SSN:
Coverage Election
Person Has Other
Medical
Medicare-eligible
Insurance
Name: ________________
Y
N
Y
N
Y
N
Relationship: ____________
Date of Birth: __________
Male
Female
SSN:
Coverage Election
Person Has Other
Medical
Medicare-eligible
Insurance
Name: ________________
Y
N
Y
N
Y
N
Relationship: ____________
Date of Birth: __________
Male
Female
SSN:
Coverage Election
Person Has Other
Medical
Medicare-eligible
Insurance
Name: ________________
Y
N
Y
N
Y
N
Relationship: ____________
Date of Birth: __________
Male
Female
SSN:
Coverage Election
Person Has Other
Medical
Medicare-eligible
Insurance
Name: ________________
Y
N
Y
N
Y
N
Relationship: ____________
Date of Birth: __________
Male
Female
SSN:
Coverage Election
Person Has Other
Medical
Medicare-eligible
Insurance
Name: ________________
Y
N
Y
N
Y
N
Relationship: ____________
Date of Birth: __________
Male
Female
SSN:
I hereby request the above action and authorize VSRS to deduct my portion of the monthly premium from my retirement check. I
understand that my first check will show a double deduction because health insurance premiums must be paid one month in
advance. Subsequent checks will show the single deduction. I understand that any medical information that is pertinent and
necessary for the payment of claims for me or my eligible dependents can be used in accordance with the privacy rules
established by the Health Insurance Portability and Accountability Act.
At age 65 or earlier, in the case of disability benefits paid by Social Security, Medicare will become the primary insurance carrier
and state medical premiums will be decreased. Should I or any of my dependents become eligible for Medicare before age 65, I
agree to notify the Retirement Office immediately. I also understand that if I do not choose Medicare when available, as my
primary insurance carrier, I will be responsible for any medical payments that would have been paid by Medicare.
I certify that the above information is complete and that all claims submitted will only be for eligible plan members.
RETIREE SIGNATURE: _________________________________________
DATE: ________________________
DHR/Benefits-Revised 10-2014
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