Superior Court of California
County of Santa Clara
191 North First Street
San José, CA 95113
Telephone: (408) 882-2703
Fax: (408) 882-2796
RETIREE MEDICAL PLAN ENROLLMENT AND CHANGE FORM
Retiree Survivor of Retiree
SECTION 1: Retiree/Survivor of Retiree Information
SECTION 2: Type of Change
Change my Medical Plan Enroll in a Medical Plan
Add Eligible Dependents Remove Dependents from Medical Plan
Open Enrollment Qualifying Event (birth, marriage, Medicare Eligibility or loss of medical coverage)
Terminate Medical Plan Coverage
SECTION 3: Medical Plan
Name of new Medical Plan*:
*All plans require submittal of provider enrollment form. Please contact Human Resources.
Name of Doctor/Medical Group (if known):
SECTION 4: Dependent Information
SECTION 5: Additional Information
If you have more than three dependents, please include their information on a separate page. Be sure to put
you name and social security number at the top of the page.
Monthly premiums vary depending on which plan you elect. See the current Retiree Medical Plan Rates or
contact Human Resources if you do not see your plan listed.
If you are enrolling eligible members on your retiree medical plan coverage, please attach marriage certificate,
affidavit of taxation for Domestic Partnership with registration, or birth certificate.
SECTION 6: Retiree/Survivor of Retiree Signature
I certify that all of the information contained in this form is true and correct. I understand that I should confirm my
effective date of coverage through Human Resources prior to seeking services from any provider. The Superior
Court of California, County of Santa Clara is not responsible for services received prior to effective date of
Human Resources Use ONLY – Do not write below this line.
Coverage start date: Premium Payments begin date: Initials:
HR-056 NEW 8/24/15
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