Fillable RETIREE NOTIFCATION FORM Group Health Coverage (City of Stephenville)

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RETIREE NOTIFCATION FORM Group Health Coverage (City of Stephenville)

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The RETIREE NOTIFCATION FORM Group Health Coverage (City of Stephenville) form is 1 page long and contains:

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  • 23 other fields

Country of origin: US
File type: PDF

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BROWSE CITY OF STEPHENVILLE (TX) FORMS

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RETIREE NOTIFCATION FORM
Group Health Coverage
NAME:
ADDRESS:
(Street Number) (Street Name) (City) (State) (Zip)
DEPARTMENT:
PHONE #
TITLE:
RETIREMENT DATE:
□
Yes
□
No
Are you retiring under the Texas Municipal Retirement System?
□
Yes
□
No
Have you been continually employed with the City of Stephenville for the last five years?
□
Yes
□
No
Do you have other group health insurance available to you?
□
Yes
□
No
Does your spouse or covered dependents have other group health insurance available to them?
□
Yes
□
No
Do you agree to inform the City of Stephenville if you or a covered member of your family become
covered under another group health plan or entitled to Medicare?
□
Yes
□
No
Do you understand that premium amounts will change from year to year?
□
Yes
□
No
Do you understand that you are responsible for remitting the full amount of the premium by a specific
date, and if you fail to remit the required amount coverage will terminate for you and your dependents?
DECLINATION
(initial) I understand that I am eligible for group health coverage continuation: however, I hereby decline retiree
health coverage. I understand that this is the only opportunity I will have to continue the City’s group health coverage.
I understand that I also have the right to continue coverage subject to COBRA provisions for up to 18 months, and this
declination will not jeopardize those rights under COBRA.
I certify by signature below that I have read the retirement provisions described in the Stephenville Policy manual.
Employee Signature: Date:
APPENDIX E
FORM 23
Page 230 of 254
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RETIREE NOTIFCATION FORM Group Health Coverage (City of Stephenville)

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Completed 16 July 2020

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