Type or print and forward to the retirement services division insurance is effective the first of the month following the retirement date retiree name




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CHOICE OF HEALTH SERVICES AFTER RETIREMENT

CO-744 REV. 4/2014



TYPE OR PRINT AND FORWARD TO THE RETIREMENT SERVICES DIVISION

INSURANCE IS EFFECTIVE THE FIRST OF THE MONTH FOLLOWING THE RETIREMENT DATE

RETIREE NAME (Person Receiving Benefit) (Last Name, First Name, MI)

RETIREMENT DATE

EMPLOYEE NUMBER (From Active Employment)

     

     

     

MAILING ADDRESS

TELEPHONE NUMBER

     

     

YOUR OPTIONS

This statement lists your benefit options. Use this page to select your medical and dental coverage. Note that your choices will remain in effect throughout this plan year unless you experience a change in family status. Please keep a copy of this form for your records. Please be aware that you and any dependents who enroll in medical coverage must also enroll in prescription coverage and that prescription coverage is not available to individuals who are not enrolled in a medical plan.

Check the box to the left of the plan you wish to select.

MEDICAL

ANTHEM

OXFORD

 Waive/Cancel Medical and Prescription Coverage

 State BlueCare POS


 State BlueCare POE

 State BlueCare POE Plus POE-G

 State Preferred POS – Currently Enrolled Only

 Out of Area Plan – Only if Retiree’s Permanent Residence is Outside of Connecticut

 Oxford Freedom Select POS

 Oxford HMO Select POE


 Oxford HMO POE-G

 Oxford USA - Out of Area Plan – Only if Retiree’s Permanent Residence is Outside of Connecticut


DENTAL

 Basic Dental Plan

 Enhanced PPO Dental Plan

 Dental HMO Plan

 Waive/Cancel Dental Coverage


RETIREE/DEPENDENTS

List you and all of your dependents to be enrolled in health coverage. Note that the retiree must be enrolled in a health plan to be able to enroll eligible dependents. Attach sheets to list additional dependents. If any listed dependent age 19 or over is disabled, attach special application for covered dependent, which may be obtained from the Retirement Health Insurance Unit.






NAME

RELATIONSHIP

(i.e., Spouse, Son, Daughter)



GENDER

DATE OF BIRTH

SOCIAL SECURITY NUMBER

MEDICAL & PRESCRIPTION

DENTAL

F

M

     

Retiree





     

     





     

Dependent 1:





     

     





     

     

Dependent 2:





     

     





     

     

Dependent 3:





     

     





     




COORDINATION OF BENEFITS – APPLICATION IS INVALID UNLESS THIS SECTION IS COMPLETED

When you are covered by the Health Plan Selected will you or your dependent(s) have any other coverage?  Yes  No



If yes, which family member(s) will be covered by that insurance? (Check off as many that apply)

 Self  Spouse  Children (List Names):      


NAME OF PLAN

ADDRESS

     

     

POLICY NUMBER

NAME OF PERSON(S) POLICY ISSUED TO

     

     

EFFECTIVE DATE

COMPANY THROUGH WHICH COVERAGE OBTAINED

     

     

Is any member listed above eligible for Medicare?  Yes  No

If yes give Medicare Part A (Hospital Insurance) and Medicare B (Medical Insurance) effective date(s):

RETIREE

Dependent 1

Dependent 2

Dependent 3

PART A (MO/YR)

PART B (MO/YR)

PART A (MO/YR)

PART B (MO/YR)

PART A (MO/YR)

PART B (MO/YR)

PART A (MO/YR)

PART B (MO/YR)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

ARE YOU PRESENTLY RECEIVING WORKERS’ COMPENSATION?  YES  NO


I hereby apply for membership in the plan(s) above. I understand that if I am changing plans, my current coverage will be canceled when my new coverage takes effect. I understand that the services will be available subject to exclusions, limitations, and conditions described by the health plan.

I certify that all information on this form is correct to the best of my knowledge and belief, and understand that providing false and/or incomplete information may result in the rescission of coverage and/or nonpayment of claims for myself or my eligible dependent(s). I hereby authorize the State Comptroller to make deductions, if applicable, from my pension check for the medical and/or dental insurance indicated above.



RETIREE SIGNATURE (Person Receiving Benefit)

DATE

     

     

THIS SECTION TO BE COMPLETED BY AUTHORIZED AGENCY PERSONNEL

Is this employee currently enrolled in or eligible for a state-sponsored Medical or Dental Plan for which the State pays all or part of the premium?

 YES  NO

If enrolled, provide current medical and/or dental plan:

     

Employing Agency:

     

Agency Telephone Number:

     

Preparer’s Name:

     

Preparer’s Signature:

     

(Print Name of Authorized Agency Employee)







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