Get State Of Iowa Employer Group Retiree Program N Application - Benefits Iowa

This guide will assist you in completing the State Of Iowa Employer Group Retiree Program N Application for benefits. Follow the simple steps outlined below to ensure your application is filled out accurately and submitted online.

Follow the steps to complete your application online.

1. Use the 'Get Form' button to access the application form online.
2. Begin by filling out Section A, where you will enter your name, contact information, date of birth, and social security number. Make sure to indicate your gender and the effective date of coverage.
3. In Section B, select the reason for changing your contract, such as marriage or loss of other coverage. Provide the corresponding date of the event and a brief explanation if needed.
4. Section C requires information regarding Medicare coverage. Fill in the name of the individual covered by Medicare, as well as their Medicare ID number and effective dates for Parts A and B.
5. For Section D, disclose any other health coverage you may have. Indicate whether you will maintain that coverage and provide the required policy information.
6. If you choose to waive health benefits, check the appropriate box in Section E and provide the reason for waiving coverage.
7. In Section F, select your preferred payment method for premiums. Fill out the details for automatic account withdrawal if applicable, including your financial institution's information.
8. Complete the Authorization and Certification section by signing and dating the application to confirm that all information provided is true and complete.
9. Once all sections are filled out, you can save changes, download your completed form, print it for your records, or share it as needed.

Complete your employer group retiree application online today to ensure timely processing.