Retiree Benefits Application

Retiree Benefits Application

WHEREAS

WHEREAS Employer Name: (the "Employer") maintains benefit programs for eligible former employees; and

WHEREAS Retiree Name: (the "Retiree") has separated from employment and seeks enrollment in the Employer's retiree benefit programs in accordance with program terms and applicable plan documents; and

WHEREAS the parties desire to document the Retiree's application for benefits, the services to be provided, payment terms, and the parties' respective obligations;

Applicant Information

Benefit Selection

Select the retiree benefits for which you are applying (check all that apply):

Medical coverage

Dental coverage

Vision coverage

Life insurance continuation

Pension stipend / monthly benefit

Dependents / Beneficiaries

Scope of Work

Describe the benefits, services, or administrative actions requested and authorized under this application. Include any special provisions for continuation coverage, reimbursement, or third-party services to be provided to the Retiree.

Payment Terms

Amount payable to Retiree (if applicable) or monthly benefit amount:

If direct deposit is requested, provide account details below and attach authorization for ACH debit/credit where required.

Term and Termination

Effective date:   Termination date (if any):

Notice period required for termination by either party:

Employer may suspend or terminate benefits for cause, including material misrepresentation, failure to provide required documentation, or nonpayment as set forth in this application and applicable plan documents.

Confidentiality

The parties acknowledge that the application and any supporting documents may contain confidential personal and plan-related information. Employer and Retiree each agree to maintain the confidentiality of such information and to use it only for purposes of administering and receiving benefits under this application, except as required by law or court order. Unauthorized disclosure of protected health information or other confidential data may subject the disclosing party to penalties under applicable privacy laws.

Governing Law

This application and any resulting obligation shall be governed by and construed in accordance with the laws of the state of , without regard to conflict of laws principles.

Entire Agreement

This application, together with any attached enrollment forms and plan documents expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior or contemporaneous written or oral agreements. Any amendment must be in writing and signed by both parties.

Certifications and Authorizations

By signing below, the Retiree certifies under penalty of perjury that all information provided in this application is true, complete, and accurate to the best of the Retiree's knowledge. The Retiree authorizes the release of information necessary to verify eligibility and to administer benefits, including contact with prior employers, insurers, and financial institutions as required by the Employer.

I certify that the information provided is true and correct.

I authorize release of information necessary to process this application.

Retirement letter / separation notice

Proof of age / identity

Dependent eligibility documents (if applicable)

Acknowledgment

The undersigned Retiree acknowledges that enrollment in retiree benefits is subject to the terms and conditions of the Employer's plan documents and that acceptance of this application is contingent upon verification of eligibility. Employer's acceptance of this application is evidenced by Employer's authorized signature below.

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