Retiree coverage election form (form A) 2020-2025

1. Click ‘Get Form’ to open the Retiree coverage election form (form A) 2020 in the editor.
2. Begin with Section 1, where you will enter your subscriber information. Fill in your last name, first name, middle initial, date of birth, and Social Security number using capital block lettering.
3. Provide your contact details including phone numbers and address. Ensure all information is accurate to avoid delays in coverage.
4. In Section 2, list any eligible spouse or state-registered domestic partner you wish to cover. Include their details and indicate if they are subject to the tobacco use premium surcharge.
5. Proceed to Section 3 for medical plan selection. Choose one option that best fits your needs from the available plans.
6. Complete Section 5 if making changes to an existing account. Indicate any changes clearly and provide necessary documentation as required.
7. Finally, sign and date the form in Section 6 before submitting it back through our platform for processing.

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