Fillable 2022 Stanislaus County Early Retiree Benefit Enrollment Form

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2022 Stanislaus County Early Retiree Benefit Enrollment Form

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Revised 10/01/2021 Page 1 of 2
CHIEF EXECUTIVE OFFICE
Human Relations Division
Employee Benefits
1010 10
th
Street, Suite 5900, Modesto, CA 95354
Phone: 209.525.5717 Fax: 209.525.5779
earlyretirees@stancounty.com
2022 Stanislaus County Early Retiree Benefit Enrollment Form
Please complete this benefit enrollment form in its entirety when enrolling or making changes to your Medical
Benefit. Refer to your Benefit Guide for detailed information on your medical plan options. Check the box next
to the option of your choice. Enter all dependent information if necessary. If there is a Qualifying Life Event
change, submit this completed form and backup documentation within 60 days of the qualifying event. Certified
marriage and/or birth certificates along with social security numbers are required when enrolling a new
dependent in a health plan.
1. Main Subscriber’s General Information
Open Enrollment
Qualifying Life Event Change Type :
Change Date:
ID #: For office use
Last Name:
First Name:
Middle Initial:
New Last Name:
Home Address:
State:
Zip Code:
Home Phone:
Cell Phone:
Gender:
Male Female
Date of Birth:
Social Security #:
Marital Status:
Married Single
E-Mail Address:
Main Subscriber:
Retiree Spouse Beneficiary
Are you covered by Medicare? Yes No
If you marked Yes, you are not eligible to enroll in this plan.
2. Select Your Medical Coverage
Health Plan of Northern California (HPNC) or UnitedHealthcare (UHC) based on physical home address
Level of Coverage
Retiree
Spouse
Dependent(s)
High Deductible Health
Plan (HDHP)
Exclusive Provider
Organization (EPO)
3. Dependent Information – Complete all dependent information below
Marriage and/or birth certificates, and social security numbers are required for dependents
Dependent Name
Social Security #
Relationship
Date of Birth
Sex
Add
Delete
1.
2.
3.
4.
Revised 10/01/2022 Page 2 of 2
4. Acceptance Agreement – Please read the following and acknowledge by signing below
I understand that I may continue my medical benefits for myself and my covered eligible dependents, upon
retirement. In order to qualify, I know that I, and/or my dependents, cannot be covered by another group health
plan through another source, including Medicare. I understand that when I, and/or my dependents, turn 65, I,
and/or my dependents, will be canceled from this medical plan.
I understand that by signing below, I am acknowledging my enrollment in the medical plan option selected on
this enrollment form. Should changes take place affecting eligibility of this enrollment, I will immediately inform
Stanislaus County Employee Benefits of the change. Any misstatements or omissions may result in future
claims being denied and/or the policy being rescinded.
I understand that the County will continue to establish medical insurance premium rates each year based on
actuarial and underwriting recommendations and the County reserves the right to adjust medical insurance
premium rates based on these recommendations. I further understand that I am responsible for paying any
increase in monthly premium rates made due to these recommendations.
I understand that monthly premium payments are due the 1
st
of every month and can be paid by check, money
order or, if eligible, deduction from my StanCERA retirement benefit. I understand that StanCERA will not take
partial deductions from my retirement check. If there is not enough money to cover my full medical plan
deduction, I agree to pay the total premium owed to Stanislaus County Employee Benefits directly by check
or money order. If payment is not received by the 1
st
of the month, my coverage may be canceled.
This authorization will remain in effect until it is revoked in writing by the County, myself or I attain age 65. I
will submit any revocations in writing to Stanislaus County Employee Benefits. I am entitled to a copy of this
signed authorization for my files.
Subscriber Signature:
Date:
5. Authorization of Deduction by Recipient of Monthly Retirement Benefit
Retiree Spouse Beneficiary
Last Name:
First Name:
Social Security #:
By signing this form, I hereby authorize StanCERA to deduct from my retirement benefit the amount requested
by Stanislaus County Employee Benefits and pay that amount to Stanislaus County Employee Benefits. I
understand that StanCERA deducts members’ premiums as a courtesy and that StanCERA has no duty or
obligation to verify the accuracy of any information provided by its members or Stanislaus County Employee
Benefits. I agree that StanCERA is not responsible for determining the amount that should be deducted to
cover the cost of my current premiums. I further agree not to hold StanCERA liable for any discrepancy in
premiums deducted from my retirement benefit. If a discrepancy in the amount withheld arises, I will contact
Stanislaus County Employee Benefits directly to remedy the issue, and should any additional payment or
refund be required, I will handle such transaction with Stanislaus County Employee Benefits directly.
I agree that StanCERA is neither a party nor beneficiary to my agreement with Stanislaus County Employee
Benefits and that StanCERA is hereby released from liability for negligence, intentional acts, damages, or any
other claims (known or unknown) arising from my agreement with Stanislaus County Employee Benefits.
This authorization will remain in effect until it is revoked in writing by StanCERA, myself or I attain age 65. I
will submit any revocations in writing to Stanislaus County Employee Benefits.
Recipient Signature:
Date:
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2022 Stanislaus County Early Retiree Benefit Enrollment Form

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Completed 3 April 2022

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