Side 1 of Form

Your SSN/SSN of Deceased PERA Member/Retiree

Print your Social Security number inside the boxes provided. If you are not the PERA member, print the Social Security number for the deceased PERA member or retiree in the second row of boxes.

Complete your full name, date of birth, and daytime telephone number.

Signature

Sign the form. By doing so you are certifying that you have read the PERACare 2010 Health Benefits Program Pre-Medicare Coverage booklet and are agreeing to the terms and conditions of the PERACare program listed in the Signature Certification box.

Effective Date

This is the date that you want health care coverage under PERACare to become effective.

If you are not enrolling during open enrollment, the effective date should coincide with the date your prior coverage ends. If the date you want coverage to be effective is different from your retirement effective date, you may have to complete a Certification of Previous Health Care Coverage form (see the PERACare Enrollment Eligibility Chart for details).

Spouse Enrollment Information

Complete this section if you want to enroll your spouse in any of the plans (health, dental, or vision) available through PERACare.

Side 2 of Form

Health Plan Selection

Select your coverage level (who you want to enroll in a health plan). If you are enrolling dependent child(ren), make sure you complete the Dependent Child(ren) Enrollment Information section of the form.

Select the plan in which you are enrolling. Information about each plan, including premiums, is included in the PERACare 2010 Health Benefits Program Pre-Medicare Coverage booklet.

If you are enrolling in the Anthem HMO Plan: You must select a primary care physician for yourself as well as for your spouse and child(ren) (if applicable) by completing the provider code section. Provider codes can be found on the provider directory page. You may also call Anthem at 1-877-PERABLU (1-877-737-2258) for provider codes.

Dental Plan Selection

Select your coverage level (who you want to enroll in a dental plan). If you are enrolling dependent child(ren), make sure you complete the Dependent Child(ren) Enrollment Information section of the form.

Select the dental plan in which you are enrolling. Information about each plan, including premiums, is included in the PERACare 2010 Health Benefits Program Pre-Medicare Coverage booklet.

If you are enrolling in CIGNA Dental HMO: You must select a dentist for yourself as well as for your spouse and child(ren) (if applicable) by completing the provider code section. Provider codes can be found on the provider directory page. You may call CIGNA Dental at 1-877-635-PERA (7372) for provider code(s). PERA cannot complete your enrollment if you do not provide this information.

Vision Plan Selection

Select your coverage level (who you want to enroll in a vision plan). If you are enrolling dependent child(ren), make sure you complete the Dependent Child(ren) Enrollment Information section of the form.

Select the vision plan in which you are enrolling. Information about each plan, including premiums, is included in the PERACare 2010 Health Benefits Program Pre-Medicare Coverage booklet. If you select a coverage level and do not select a plan here, you will be enrolled in VSP PPO#1.

Dependent Child(ren) Enrollment Information

Complete this section if you are enrolling dependent child(ren) under any of the plans (health, dental, or vision).