Get the free 2017 Retiree Enrollment Form dr 2.xlsx

2017 PE BTF Open Enrollment Form for REP Members This form should be completed only if you are not Medicare eligible, and you want to make a plan change for 2018. All other changes must be reported

How to fill out 2017 retiree enrollment form

How to fill out 2017 retiree enrollment form

1. Read the instructions on the 2017 retiree enrollment form carefully.
2. Fill out your personal information accurately, including your name, address, Social Security number, and date of birth.
3. Provide information about your current or previous employer, such as the name, address, and dates of employment.
4. Select the retiree health plan option that best suits your needs.
5. Specify whether you wish to enroll in any additional coverage options, such as dental or vision plans.
6. If applicable, provide information about your spouse or dependent(s) including their names and Social Security numbers.
7. Sign and date the form to certify the accuracy of the information provided.
8. Keep a copy of the filled-out form for your records.
9. Submit the completed form according to the instructions provided, either by mail or electronically.

Who needs 2017 retiree enrollment form?

1. The 2017 retiree enrollment form is needed by retirees who are eligible for retiree health benefits and wish to enroll in a retiree health plan for the year 2017.

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