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RETIREE NOTICE OF ELECTION (NOE) R SOUTH CAROLINA …

REV. 2/4/2020 ORIGINAL TO PEBA COPY TO ENROLLEE You must also complete a Certification Regarding Tobacco Use form within 31 days of enrolling in health coverage and whenever the status of tobacco use changes for you or a dependent covered under your health social security number orBIN2. Last Name3. SuffixRETIREE NOTICE OF ELECTION (NOE) SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITYRSee Instructions - if completing by hand use black inkSelect OneRegular RetireeDisability RetireeELIGIBILITYENROLLEE INFOCOVERAGEMF4. First Name5. Date of Birth (MM/DD/YYYY)10. Email Address9. Home Phone #7. Sex12. Mailing Address13. City14. State15. Zip Code16. County Code17. HEALTH PLAN (Refuse or select one plan and one level of coverage)PLANCOVERAGE LEVELS tandardRefuseSavings (not Medicare-eligible)TRICARE Supplement (not Medicare-eligible)Retiree19.

Social Security number or. BIN 2. Last Name. 3. Suffix ... I have provided Social Security numbers and documentation establishing my ... Employment Verification Record form. If you initially became eligible for insurance before May 2, 2008, and you have fewer than 10 years service credit, or if

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South Carolina Retirement System Member …

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