SI 7533-642682-C (3/15) ARE YOU ENROLLED IN THE STATE OF NEVADA PEBP SPONSORED MEDICAL PLAN OR MEDICARE PLAN? YES NO If you answered YES and you are not a reinstated retiree or a survivor, then PEBP provides you with $12,500 of Basic Life coverage. You may elect additional life insurance for yourself by indicating below. Check with your Human Resources Department about eligibility and Evidence of Insurability requirements. VOLUNTARY LIFE INSURANCE Retiree (Multiples of $5,000 to $50,000) Please note: Current Voluntary Life amount does not include Basic Life amount provided by the State. $ + = MEMBER INFORMATION Enrollment Change Initial Enrollment Increase Coverage Address Change Other Late Applicant Reduce Coverage Name Change Terminate Coverage Check all box(es) and complete all sections that apply. Mail completed form to the address listed below. Voluntary Life Enrollment and Change Form For Retired Employees Standard Insurance Company Group Name Group Number Division ID Retiree Type Your Name (Last, First, Middle) If name change, what was your former name? Your Mailing Address City State Zip Home Phone Date of Birth Gender Date of Retirement Soc. Sec. No. Male Female State of Nevada Public Employees' Benefits Program 642682-C Retiree 888.288.1270 Tel State Non-State COVERAGE SECTION Please retain a copy for your records. I wish to apply for insurance under the Group Insurance Plan, or to authorize the changes noted above. I authorize deductions from my PERS retirement benefit check to cover my contribution, if required, toward the cost of insurance. I understand that my deduction amount will change if my coverage or costs change. SIGNATURE Retiree Signature Required Date (Mo/Day/Yr) INSTRUCTIONS Please return completed form in the enclosed self-addressed envelope: State of Nevada Life Insurance Team Mestmaker Insurance Services P.O. Box 2302 Bakersfield, CA 93303-2302 Current Voluntary Life Amount with The Standard Additional Amount Requested Total Amount Requested

Voluntary Life Enrollment and Change Form for Retirees ... · Title: Voluntary Life Enrollment and Change Form for Retirees - State of Nevada Public Employees' Benefits Program, 7533_642682c.pdf

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Page 1: Voluntary Life Enrollment and Change Form for Retirees ... · Title: Voluntary Life Enrollment and Change Form for Retirees - State of Nevada Public Employees' Benefits Program, 7533_642682c.pdf

SI 7533-642682-C (3/15)

ARE YOU ENROLLED IN THE STATE OF NEVADA PEBP SPONSORED MEDICAL PLAN OR MEDICARE PLAN? YES NO

If you answered YES and you are not a reinstated retiree or a survivor, then PEBP provides you with $12,500 of Basic Life coverage. You may elect additional life insurance for yourself by indicating below. Check with your Human Resources Department about eligibility and Evidence of Insurability requirements.

VOLUNTARY LIFE INSURANCE

Retiree (Multiples of $5,000 to $50,000) Please note: Current Voluntary Life amount does not include Basic Life amount provided by the State.

$ + =

FOR

TIO

Enrollment ChangeInitial Enrollment Increase Coverage Address Change Other

Late Applicant Reduce Coverage Name Change Terminate Coverage

Check all box(es) and complete all sections that apply. Mail completed form to the address listed below.

Voluntary Life Enrollment and Change FormFor Retired Employees

Standard Insurance Company

Group Name Group Number Division ID Retiree Type

Your Name (Last, First, Middle) If name change, what was your former name?

Your Mailing Address

City State Zip Home Phone

Date of Birth Gender Date of Retirement Soc. Sec. No. Male Female

State of Nevada Public Employees' Benefi ts Program 642682-C Retiree

888.288.1270 Tel

State Non-State

ION

Please retain a copy for your records.

I wish to apply for insurance under the Group Insurance Plan, or to authorize the changes noted above. I authorize deductions from my PERS retirement benefi t check to cover my contribution, if required, toward the cost of insurance. I understand that my deduction amount will change if my coverage or costs change.

SIG

Retiree Signature Required Date (Mo/Day/Yr)

INST

ION

S Please return completed form in the enclosed self-addressed envelope:

State of Nevada Life Insurance TeamMestmaker Insurance ServicesP.O. Box 2302Bakersfi eld, CA 93303-2302

Current Voluntary Life Amount with The Standard

Additional Amount Requested Total Amount Requested