State Health Benefits Program Retiree Enrollment Form

1 Commonwealth of Virginia State Health Benefits Program Enrollment Form For Retirees, Survivors and LTD Participants Part A. Enrollee Information ( Retiree , Survivor or LTD Participant Information Only Not Family Member Information)n Check here if this is an address change. Social Security Number _____ Print Name _____ Health Plan Identification Number_____(First)( )(Last) Day Time Phone (_____) _____ Birth Date _____/_____/_____ Sex: n Male n Female E-mail Address _____MonthDayYearREASON FORM IS BEING SUBMITTED (Check each appropriate category)n Initial Enrollment . Check one: l RetirementlVSDP LTD initial Enrollment /waiver or other LTD initial enrollmentlSurvivor Enrollment l Re-enrolling from family member status in active/other Retiree coverage or from other active eligibility (Date losing other coverage _____ )nNow Eligible For Medicare.

Vision & Hearing (ACC5) n COVA HealthAware (with preventive dental) (CHA) n COVA HealthAware + Expanded Dental (CHA2) ... Benefits Program, and that cancellation of prescription drug and/or Dental/Vision benefits will preclude any future enrollment for those benefits. I understand that my health premiums are subject to change.

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