VCPFA Retiree Form

1

Name* This field is required.

First Name

Middle Name

Last Name

2

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

3

Phone Number* This field is required.

Area Code

Phone Number

4

E-mail* This field is required.

5

Birth Date

6

Retirement Date* This field is required.

Date

7

Marital Status* This field is required.

8

Name of Spouse/DP

First Name

Last Name

9

I am currently on a VCPFA Medical Plan* This field is required.

YesNo

10

I wish to continue on my VCPFA Medical Plan as a retiree* This field is required.

YesNo

11

I wish to change my VCPFA Medical Plan as a retiree* This field is required.

YESNO

12

I wish to change to the following plan

Blue Shield Trio HMO

Blue Shield HMO High

Blue Shield HMO Low

Blue Shield HDHP PPO

13

I am currently on a VCPFA Dental Plan* This field is required.

YesNo

14

I wish to continue on my VCPFA Dental Plan as a retiree

YesNo

15

I am currently on a VCPFA Vision Plan* This field is required.

YesNo

16

I wish to continue on my VCPFA Vision Plan as a retiree

YesNo

17

I wish to add or drop dependent(s) to my plan at retirement* This field is required.

YESNO

18

I wish to drop the following dependents at retirementEnter Names

19

Drop listed Dependents from the following plansSelect all that apply

Medical

Vision

Dental

20

Retiree BillingI understand that VCPFA may bill me directly for any premiums not deducted by VCERA upon retirement.

Your initials acknowledge understanding of other group coverage requirements.

21

Other group coverage understandingI do not wish to continue my VCPFA Medical plan and I have requested that the Association cancel my medical insurance upon retirement. I understand that when I cancel my medical benefits through the Association unless I am participating in another employer group health insurance plan (through myself or my spouse) that I will not be able to opt back into the Association health plan at a later date.

Your initials acknowledge understanding of other group coverage requirements.

22

Other Coverage ElectionCheck all that apply

I am not providing proof of other group health insurance, but still wish to cancel my group health insurance through VCPFA. I will not be eligible for medical insurance through VCPFA at a later date.

I am canceling/not enrolling into VCPFA retiree medical insurance and am NOT enrolling in another eligible GROUP health plan. I will not be eligible for medical insurance through VCPFA at a later date.

I am enrolling in another group health plan through myself or a spouse’s employer.

I will send a copy of my new health insurance cards within 60 days of my cancellation of this VCPFA medical insurance plan with an effective date of 30 days or less past the cancellation of my VCPFA group medical insurance policy.

23

Submit Proof of Coverage (optional)Upload proof of other coverage here

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