Fillable Health / Dental Insurance Deduction Authorization Form (Port of Richmond)

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Health / Dental Insurance Deduction Authorization Form (Port of Richmond)

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Health / Dental Insurance
Deduction Authorization Form
PART A. MEMBER INFORMATION
Mailing Address
City/State/ZIP
STEP 1
Please fill out your form,
typed or printed in ink,
and remember to sign.
STEP 2
Submit your form...
...during our walk-in hours,
Monday thru Friday,
10AM-12PM and 1PM-3PM,
with a Photo ID
or
...by mailing your form to:
Richmond Retirement System
730 E. Broad Street, Suite 900
Richmond, VA 23219
THANK YOU!
PART B. HEALTH INSURANCE
PART E. CERTIFICATION
I hereby authorize the RRS to deduct all required premiums, and I acknowledge that I
understand:
(1) In accordance with policies provided to the RRS, changes can only be made during open
enrollment or within 30 days of a qualifying event.
Signature Date
The City of Richmond Department
of Human Resources (HR)
administers certain post-
employment benefits.
This form is for members who are
eligible for health and dental
insurance benefits.
DIRECTIONS
Richmond Retirement System | 730 E. Broad Street, Suite 900, Richmond, Virginia, 23219 | Tel: (804) 646 - 5958 | Fax: (804) 646-5299 | www.richmondgov.com/retirement
Form revised June 2016
I am a Power of Attorney or guardian, and documentation is attached
I am the member
I am aware that health insurance benefits are more expensive for retirees than for employees.
I am aware that HR will determine the premiums I must pay in retirement (not the RRS).
I would like to select the following:
PLAN B - ClassicPLAN A - Premier HSA DECLINE COVERAGE
PART C. DENTAL INSURANCE
I would like to select the following:
PPODHMO DECLINE COVERAGE
Retiree + OneRetiree Only Dependent Spouse
PART D. DEPENDENT INFORMATION, IF APPLICABLE
Member Name SSN
Date of Birth Male or Female?
Family
Retiree Only Retiree + One Dependent Spouse
Family
If selecting Retiree + One or Dependent Spouse, submit information below:
NOTE: If selecting Family, an attachment should include information for eligible family members.
Email AddressPhone Number
Dependent Name
SSN
RRS USE ONLY
1.Retirement Date,
From RRS
_____________
2.Health Deduction,
From HR
$____________
3.Dental Deduction,
From HR
$____________
4.Reviewer #1
5.Reviewer #2
6.Notes:
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Health Dental Insurance Deduction Authorization Form (Port of Richmond)

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Completed 1 November 2020

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