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Retiree Notice of Election (NOE)

Retiree Notice of Election (NOE) 2025

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The document is a Retiree Notice of Election (NOE) form for health coverage enrollment, detailing eligibility requirements, action steps for retirees, and necessary information for dependents. It includes sections for selecting retiree type, health plans, dental and vision coverage, and Medicare details. The form emphasizes the importance of timely completion and submission of required documentation to ensure proper enrollment and benefits.

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Click ‘Get Form’ to open the Retiree Notice of Election (NOE) in the editor.
Begin by completing the ELIGIBILITY section. Select your retiree type and indicate your length of service. Attach your Employment Record as required.
In the ACTION section, specify if you are a new subscriber or making changes to your existing coverage. Fill in the necessary dates and details.
Proceed to ENROLLEE INFO. Complete all fields from Social Security Number to Mailing Address, ensuring accuracy for effective processing.
In the COVERAGE section, select your desired health plan and coverage level. Remember that alterations are not allowed after submission.
For MEDICARE AND OTHER COVERAGE, list any dependents eligible for Medicare and provide necessary documentation if applicable.
Complete the DEPENDENTS section by listing all eligible family members, ensuring legal documentation is attached where required.
Finally, review the CERTIFICATION & AUTHORIZATION section carefully before signing and dating the form. Submit it as instructed.

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