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SELF ENHANCED RETIREE PLAN ENROLLMENT/ENROLLMENT FORM Name: Benefit Fund ID#: BF00 Address: Cell Phone: () Email Address: Home Phone: () SELECT ONE OF THE FOLLOWING PLANS: Self Enhanced Retiree Plan

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What is retiree self-pay enhanced plan?

Retiree self-pay enhanced plan is a health insurance plan that allows retired individuals to pay for enhanced coverage on their own.

Who is required to file retiree self-pay enhanced plan?

Retired individuals who wish to have enhanced health insurance coverage are required to file the retiree self-pay enhanced plan.

How to fill out retiree self-pay enhanced plan?

To fill out the retiree self-pay enhanced plan, individuals must provide personal information, choose coverage options, and make payment arrangements.

What is the purpose of retiree self-pay enhanced plan?

The purpose of retiree self-pay enhanced plan is to provide retired individuals with additional health insurance coverage beyond what is provided by their former employer.

What information must be reported on retiree self-pay enhanced plan?

Information such as personal details, chosen coverage options, and payment arrangement details must be reported on the retiree self-pay enhanced plan.

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