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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. vision CARE (select one)Police RetireeSelect OneIndicate Record of Service (Attach Employment Record)8.

15. Zip Code 16. County Code. 17. HEALTH PLAN (Refuse or select one plan and one level of coverage) PLAN. COVERAGE LEVEL. Standard. Refuse Savings (not Medicare-eligible) TRICARE Supplement (not Medicare-eligible) Retiree. 19. VISION CARE (select one) Police Retiree. Indicate Record of Service . Select One (Attach Employment Record) 8. Marital ...

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