Form Gbd-1540 Va - Group Retiree Health Insurance Plan Enrollment Form
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1
2Group Retiree Health Insurance Plan Enrollment Form
Hartford Life & Accident Insurance Company
Policy Numbers: AGP-3844
Policyholder: STAFFORD COUNTY PUBLIC SCHOOLS
Please print clearly in ink or type
Retiree’s Name:
First
Middle
Last
Street:
City, State, Zip:
Medicare/HIC #
Phone Number: _____________________________________
Email Address: ____________________
Gender
Male
Female Date of Birth ___________
Social Security # ______________________
Date of Retirement _________________ Have you enrolled in Medicare Part B?
Yes
No
If no, when do you intend to enroll? ______________________________________________________________
Dependent Spouse’s Name (Only if enrolling): ____________________________________________________
First
Middle
Last
Gender
Male
Female Date of Birth ______________
Social Security # ___________________
Medicare/HIC #
Date of Retirement ___________________________
Has your dependent spouse enrolled in Medicare Part B?
Yes
No
If no, when does he/she intend to enroll? _________________________________________________________
Dependent Domestic Partner’s Name (Only if enrolling): ___________________________________________
First
Middle
Last
Gender
Male
Female Date of Birth ______________
Social Security # ___________________
Medicare/HIC #
Date of Retirement ___________________________
Has your dependent domestic partner enrolled in Medicare Part B?
Yes
No
If no, when does he/she intend to enroll? _________________________________________________________
To the best of your knowledge:
1. Do you or your dependent spouse, domestic partner if enrolling have any other health insurance including an
employer health plan? Retiree
Yes
No Dependent Spouse
Yes
No
Domestic Partner
Yes
No
If so, with which company? What kind of policy? ___________________________________________________
Covered Person
Company Name
Policy Number Kind of Policy
Effective Date Expiration Date
Form GBD-1540 VA
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