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Fillable Online The Power Ten series of high power DC ... 2025

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The document is a Public Safety Officer Insurance Premium Payment Authorization Form, which allows qualified public safety officers to authorize the payment of their health and long-term care insurance premiums directly from their retirement plan account. It includes sections for personal data, payment method, and authorization, requiring the submission of a premium notice and adherence to specific deadlines.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal data. Fill in your name, home address, date of birth, city, state, zip code, and home telephone number. If you are updating your address, check the box provided.
In the Payment Method section, specify the amount you wish to authorize for transfer and select your payment frequency from the options available: One Time, Monthly, Quarterly, Semi-Annually, or Annually.
Provide the insurance carrier's name and mailing address along with the city, state, and zip code. Remember to attach a copy of the insurance premium notice as it is required for processing.
Complete the Authorization section by signing and dating the form. Ensure all information is accurate to avoid delays in processing.

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