Get the free RETIREE/SURVIVOR Medical/Dental/Vision Form

OPEN ENROLLMENT RETIREE/SURVIVOR Medical/Dental/Vision Form BENEFITS DIVISION P. O. BOX 248 Houston TX 77001-0248 PRINT OR TYPE WITH BLUE OR BLACK INK ONLY Employee I. Medical Plan select one Cigna Limited Network Plan Cigna KelseyCare Renaissance Memorial Hermann Health Network Cigna Open Access Consumer Driven Health Plan Retirees of Texas Option Plus Dental Plan select one DHMO Plan DPPO Plan Dental Coverage Type Retiree/Survivor Only More Dependents Medical Coverage Type Retiree Spouse...

How to fill out retireesurvivor medicaldentalvision form

How to fill out retireesurvivor medicaldentalvision form

1. Obtain a copy of the retireesurvivor medicaldentalvision form from the appropriate source.
2. Read the form instructions carefully to ensure you understand the requirements and information needed.
3. Start by filling out the personal information section, including your name, address, and contact details.
4. Provide the necessary details about the deceased retiree or survivor, such as their name, date of birth, and social security number.
5. If applicable, include information about any dependent family members who are eligible for coverage.
6. Indicate the desired medical, dental, and vision coverage options by selecting the appropriate boxes or writing in the necessary details.
7. Include any supporting documents or proofs that may be required, such as marriage certificates or proof of dependent status.
8. Double-check the completed form for accuracy and make any necessary corrections before submission.
9. Sign and date the form in the designated areas to certify the information provided is true and accurate.
10. Submit the form through the designated method (mail, online portal, etc.) as specified in the form instructions.

Who needs retireesurvivor medicaldentalvision form?

1. Retirees or survivors who require medical, dental, and/or vision coverage need to fill out the retireesurvivor medicaldentalvision form.
2. This form is typically needed when enrolling for or making changes to the healthcare coverage provided to retirees and survivors.
3. Dependent family members who are eligible for coverage may also be required to complete this form.
4. Individuals seeking coverage for themselves or on behalf of their eligible dependents should submit the retireesurvivor medicaldentalvision form.

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What is retireesurvivor medicaldentalvision form?

The retireesurvivor medicaldentalvision form is a document used to enroll in medical, dental, and vision benefits as a retiree or survivor.

Who is required to file retireesurvivor medicaldentalvision form?

Retirees and survivors who wish to enroll in medical, dental, and vision benefits are required to file the retireesurvivor medicaldentalvision form.

How to fill out retireesurvivor medicaldentalvision form?

To fill out the retireesurvivor medicaldentalvision form, individuals need to provide personal information, select desired benefits, and sign the form.

What is the purpose of retireesurvivor medicaldentalvision form?

The purpose of the retireesurvivor medicaldentalvision form is to enroll retirees and survivors in medical, dental, and vision benefits.

What information must be reported on retireesurvivor medicaldentalvision form?

The retireesurvivor medicaldentalvision form requires information such as name, address, beneficiary details, benefit selections, and signature.