Get ND New Hire Forms Checklist 2021-2024

Additional funds will also be required to make up the employee contribution rates. Complete an NDPERS/TFFR MEMBERSHIP ELECTION SFN 52727. The address of MIB s information office is 50 Braintree Hill Park Suite 400 Braintree MA 02184-8734. Employer to deduct the current premium from my wages or salary and remit to NDPERS. NDPERS website at www. Nd. gov/ndpers. 60711 ACKNOWLEDGEMENT OF OR DECLINE OFFER OF HEALTH INSURANCE COVERAGE SFN 60711 Rev. 01-2017 EMPLOYEE IDENTIFICATION FOR STATE EMPLOYEES COVERED UNDER NDPERS THROUGH SPOUSE OR PARENT Affordable Care Act. Evidence of Insurability form EOI must be completed for amounts larger than 5 000 and approved by the Carrier. I understand that I can not participate in the flex comp medical spending account if I am covered on the NDPERS High Deductible Health Plan HDHP with a Health Savings Account HSA. Direct my employer to deduct the current premium from my wages or salary and remit to NDPERS. on the NDPERS website at www. To designate beneficiary ies for the group Life Insurance Plan please complete a Life Designation of Beneficiary SFN 53855. Your election is irrevocable. In accordance with the North Dakota Century Code Chapter 15-39. 01-09 3 if you are certified to teach in the state by the Education Standards and Practices Board and first employed and entered upon the payroll of the Department of Career and Technical Education after July 1 2007 you may elect within 90 days from date of hire to become a member of the Public Employees Retirement System or the Teachers Fund for Retirement. If an election is NOT made within 90 days from the date of hire you will be transferred to the Teacher s Fund for Retirement. Your election is irrevocable. Instruction after January 6 2001 you may elect within 90 days from date of hire to become a member of the Public Chapter 15-39-1-09 3 is irrevocable. Your election is irrevocable. PART D MEMBER AUTHORIZATION retirement enrollment. I understand that my membership will become effective immediately or at the attainment of age 18. I declare that the foregoing statements are full true and correct to the best of my knowledge and belief and are subject to the laws and penalties governing any misrepresentation and fraud. participation in the Defined Contribution plan versus the Defined Benefit plan* If you are a certified teacher and are employed with either the Department of Career and Technical Education or the Department of Public Instruction please ensure that you carefully read Sections 2 and 3 this pertains to your You must sign and date the form* Your signature should reflect the name as entered in Part A. DESIGNATION OF BENEFICIARY FOR THE GROUP RETIREMENT PLAN In compliance with the Federal Privacy Act of 1974 the disclosure of the individual s social security number on this form is mandatory pursuant to 26 U*S*C. Sec* 3402. The individual s social security number will be used for tax reporting and as an identification number. I understand that if married any initiation of dissolution or annulment of my marriage may void this designation* I have read and understand the terms and conditions listed on page two 2 of this designation* I hereby certify that the information provided on this form is true and correct to the best of my knowledge.