Ton, NJ 08625-0299 Single Were you a part time employee when you retired? Social Security Number - - Yes New Retiree Survivor Enrollment: Decedent’s SS# ___________________________________________________________ First Name MI I wish to be covered by the Retiree Dental Expense Plan 3A. MEDICAL COVERAGE (Check one box only). I do not wish to be covered under the dental plan (See instructions) AETNA HORIZON NJ DIRECT15 State Gender (M/F) Home Telephone Number - Date of Retirem.
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How to fill out the HR-0943-0913 online
Filling out the HR-0943-0913 form can be a straightforward process with the right guidance. This guide provides simple, step-by-step instructions to help users complete the Non-Medicare Retired Coverage Enrollment Application accurately and efficiently.
Follow the steps to complete the HR-0943-0913 form online.
- Press the 'Get Form' button to acquire the form and open it in your preferred online editor.
- In Section 1, provide your applicant information, including first name, last name, date of retirement, and Social Security Number. Ensure clarity by filling in one character per block, and provide required proof of Medicare enrollment if applicable.
- In Section 2, determine the type of activity you are applying for. Check 'New Retiree' for new applicants or 'Survivor Enrollment' if applicable. Ensure to choose only one option.
- Move to Section 3 (Medical Plan Selection). Check one box indicating your choice of medical coverage, if any. If opting out, specify the reason for declining or waiving coverage.
- In Section 4, make your decision regarding dental coverage, checking only one option that reflects your preference for the Retiree Dental Expense Plan.
- Section 5 is for dependent information. List all eligible dependents to be covered, including details such as names, dates of birth, and Social Security Numbers. Attach additional sheets if necessary.
- Finally, in Section 6, read the certification statement carefully, then sign and date the form. If you are submitting additional documentation, check the relevant box before concluding.
- After verifying that all sections are accurately filled, save your changes. You can then download, print, or share the form as needed.
Complete your HR-0943-0913 form online today to ensure your benefits are processed without delay.
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