Get Calhr Form 695

Filling out the Calhr Form 695, the Retiree Vision Plan Enrollment Authorization, is a straightforward process. This guide provides step-by-step instructions to assist users in completing the form accurately and efficiently online.

Follow the steps to fill out the form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section A - Retiree Information. Fill in your last name, first name, and middle initial. Provide your date of birth and social security number. Indicate the type of action you are taking, and complete your mailing address, including the city, state, and zip code. Make sure to include a contact telephone number.
3. If you have dependents, proceed to Section B - Dependent Information. For each dependent, enter their name, relationship to you, social security number, and date of birth. If necessary, attach additional pages for more dependents, ensuring that only eligible dependents are included.
4. In Section C - Enrollment Election, indicate whether you elect to enroll in a vision plan by checking the appropriate box. Authorize deduction from your retirement warrant for your share of the cost. Read the statement regarding your authorization for data transmission and continuing deductions thoroughly and sign and date the section.
5. If you are not enrolling in the Retiree Vision Plan, check the box to indicate your decision and sign and date the section.
6. Section D is for Employing Agency use only, and you do not need to fill this out. After completing all sections applicable to you, review your entries for accuracy.
7. Once everything is correctly filled out, save your changes, download the form, print it, or share it as necessary according to the instructions provided.

Complete your Enrollment Authorization online today for a smoother experience.