RETIREE NOTIFCATION FORM
Group Health Coverage
(Street Number) (Street Name) (City) (State) (Zip)
Are you retiring under the Texas Municipal Retirement System?
Have you been continually employed with the City of Stephenville for the last five years?
Do you have other group health insurance available to you?
Does your spouse or covered dependents have other group health insurance available to them?
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?
Do you understand that premium amounts will change from year to year?
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?
(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:
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