Form Retef15 - Retiree Health Benefits Enrollment And Change Form - 2016
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4STATE OF MARYLAND
RETIREE HEALTH BENEFITS ENROLLMENT AND CHANGE FORM
JANUARY 2016-DECEMBER 2016
PERSONAL DATA
PLEASE PRINT CLEARLY
NAME: ___________________________________________________________
SEX:
Male
Female
LAST
FIRST
MI
ADDRESS:__________________________________ APT/CONDO:_________
LEGAL MARITAL STATUS:
Single
Widowed
CITY: ____________________________________________________________
Married
Divorced
Limited Divorce/
STATE: ________________________________ ZIP CODE:_______________
Legal Separation
Home Phone:
( __ __ __) __ __ __ - __ __ __ __
MY STATUS:
Maryland State Retirement System Retiree or
Work Phone:
( __ __ __) __ __ __ - __ __ __ __
Surviving Beneficiary. Please indicate
relationship:__________________________
Cell Phone:
( __ __ __) __ __ __ - __ __ __ __
Optional Retirement Plan (ORP) Retiree
(i.e., TIAA-CREF) or
Personal E-mail: __________________________________________
Surviving Beneficiary. Please indicate
relationship:__________________________
Work E-mail: ____________________________________________
Satellite Retiree
Agency Name:__________________________ or
Social Security Number: __ __ __ /__ __ / __ __ __ __
Surviving Beneficiary. Please indicate
relationship:__________________________
Date of Birth: __ __ /__ __ / __ __ __ __
M M / D D /
Y Y Y Y
STATUS & ENROLLMENT/CHANGE ACTION REQUESTED
Change in Family Status
New Retiree
(See Benefits Guide for documentation requirements)
Request must be made within 60 days of the date of the qualifying event.
Effective Date: ____________
Add Dependent because of:
Last Day of State Employment: ____________
Marriage
Date: ____________
Disability Retirement?
Yes
No
Birth/Adoption/Appointed Permanent Legal Guardian
New Beneficiary of Deceased Retiree
Date: ___________
Name of Deceased: _________________________________
Other Reason: _________________________________________
__ __ __ /__ __ / __ __ __ __
Deceased SSN:
Remove Dependent because of:
Date of Retiree’s Death: ____________
Divorce/Limited Divorce/Legal Separation Date: ____________
Medicare Eligibility
Death
Date: ____________
(Attach copy of Death Certificate)
(Complete Medicare Information Section, page 3)
Dependent no longer eligible
Date: ___________
Open Enrollment - Effective January 1st
Reason: ______________________________________________
Cancel all Coverage in all Plans/Reason: _________________
___________________________________________________
Other Reason: _______________________________________
COMPLETED AND SIGNED ENROLLMENT FORMS MAY BE MAILED OR HAND-DELIVERED TO:
Employee Benefits Division
EBD Use Only:
301 W. Preston Street, Room 510
____ Reviewed
Baltimore, Maryland 21201
____ Processed
____ Audited
Hours of Operation: Monday - Friday 8:30 a.m. - 4:30 p.m.
Phone: 410-767-4775 or 1-800-307-8283 / Fax: 410-333-5191 / Email: ebd.mail@maryland.gov
Health benefits information and forms are available on our website:
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