Form BEN051 "Health Benefits Enrollment/Waiver for Retirees or Benefit Recipients / Tier I" - Alaska

What Is Form BEN051?

This is a legal form that was released by the Alaska Department of Administration - a government authority operating within Alaska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2016;
  • The latest edition provided by the Alaska Department of Administration;
  • Easy to use and ready to print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form BEN051 by clicking the link below or browse more documents and templates provided by the Alaska Department of Administration.

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Download Form BEN051 "Health Benefits Enrollment/Waiver for Retirees or Benefit Recipients / Tier I" - Alaska

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Health Benefits Enrollment/Waiver
FOR OFFICE USE ONLY
For Retirees or Benefit Recipients / Tier I
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, AK 99811-0203
Fax: (907) 465-3086
PERSONAL DATA
NAME
SOCIAL SECURITY NUMBER
Please indicate your retirement system:
PERS
TRS
EPORS
JRS
DENTAL-VISION-AUDIO BENEFITS
I elect the following Dental-Vision-Audio (DVA) coverage:
No Dental-Vision-Audio (DVA) coverage
Individual only
Individual and spouse
Individual and child(ren)
Individual, spouse, and child(ren)
LONG-TERM CARE BENEFITS
I elect the following Long-Term Care (LTC) option:
No Long-Term Care (LTC) coverage
Individual (Member) coverage:
Silver
Gold
Platinum
Spouse coverage (may elect only if member is electing individual coverage):
Silver
Gold
Platinum
Spouse’s date of birth: ______________________________________
Spouse’s SSN: ____________________________________________
I am covered under my spouse’s LTC plan.
CERTIFICATION
I acknowledge that I have been offered the two health plans available: Dental-Vision-Audio and Long-Term Care. I understand that
this is my only opportunity to enroll in these plans and that by not electing coverage at this time under either plan, I waive my right to
future participation in the DVA and LTC plan.
I authorize the deduction of premiums from my benefit check for any insurances elected above.
SIGNATURE
DATE
ben051 (Rev. 11/16)
G:\Communications_Only\200 Products\206\Benefits\ben051.indd
Health Benefits Enrollment/Waiver
FOR OFFICE USE ONLY
For Retirees or Benefit Recipients / Tier I
Division of Retirement and Benefits
Juneau: (907) 465-4460
Toll-Free: (800) 821-2251
P.O. Box 110203
TDD: (907) 465-2805
alaska.gov/drb
Juneau, AK 99811-0203
Fax: (907) 465-3086
PERSONAL DATA
NAME
SOCIAL SECURITY NUMBER
Please indicate your retirement system:
PERS
TRS
EPORS
JRS
DENTAL-VISION-AUDIO BENEFITS
I elect the following Dental-Vision-Audio (DVA) coverage:
No Dental-Vision-Audio (DVA) coverage
Individual only
Individual and spouse
Individual and child(ren)
Individual, spouse, and child(ren)
LONG-TERM CARE BENEFITS
I elect the following Long-Term Care (LTC) option:
No Long-Term Care (LTC) coverage
Individual (Member) coverage:
Silver
Gold
Platinum
Spouse coverage (may elect only if member is electing individual coverage):
Silver
Gold
Platinum
Spouse’s date of birth: ______________________________________
Spouse’s SSN: ____________________________________________
I am covered under my spouse’s LTC plan.
CERTIFICATION
I acknowledge that I have been offered the two health plans available: Dental-Vision-Audio and Long-Term Care. I understand that
this is my only opportunity to enroll in these plans and that by not electing coverage at this time under either plan, I waive my right to
future participation in the DVA and LTC plan.
I authorize the deduction of premiums from my benefit check for any insurances elected above.
SIGNATURE
DATE
ben051 (Rev. 11/16)
G:\Communications_Only\200 Products\206\Benefits\ben051.indd
Health Benefits Enrollment/Waiver Form
For Retirees or Benefit Recipients / Tier I
This form is for retirees and other benefit recipients who are
DVA Coverage for:
Premium
members of Elected Public Officers Retirement System
Individual only
$ 66
(EPORS) or Judicial Retirement System (JRS) or who were first
Individual and spouse
$131
hired under the Public Employees’ Retirement System (PERS)
Individual and child(ren)
$119
Defined Benefit plan before July 1, 1986, or under the Teachers’
Individual, spouse, and child(ren)
$187
Retirement System (TRS) Defined Benefit plan before July 1,
1990. This is your opportunity to elect to participate in two
Long-Term Care Benefits—Premium Rates by Age
separate health plans; Dental-Vision-Audio (DVA) and
Long-Term Care (LTC). You may elect either or both of the
Age
Silver Option
Gold Option
Platinum Option
at
$400,000 max
$300,000 max
$300,000 max
insurances offered. You must indicate a choice in both sections
Retire-
No inflation
Simple inflation
Compound
even if you are electing not to participate in a certain plan.
ment
protection
protection
inflation protection
40*
$26
$76
$148
If you are already covered under your spouse’s LTC plan, you
41
$27
$77
$150
cannot be covered under a second plan. Please provide your
42
$28
$78
$153
spouse’s Social Security number so we may move your LTC
43
$30
$79
$155
coverage to your retirement benefit.
44
$31
$81
$158
45
$33
$82
$161
Your form must be postmarked or received in our office before
46
$35
$84
$164
your retirement date. This is your only opportunity to enroll in
47
$37
$85
$167
these plans. If you do not enroll at this time, you waive your right
48
$39
$89
$170
49
$41
$92
$172
to participate in the future.
50
$44
$96
$175
You may decrease or terminate your coverage at any time by
51
$46
$100
$177
52
$49
$103
$180
notifying this office in writing. You may only increase DVA
53
$52
$109
$184
coverage within 120 days of the date you are married or have
54
$56
$114
$188
your first child.
55
$60
$120
$192
56
$63
$126
$195
LTC coverage may be added for your spouse within 120 days of
57
$67
$131
$199
marriage.
58
$75
$143
$212
59
$84
$156
$225
If you elect coverage, the premiums will be deducted from your
60
$92
$168
$237
benefit check each month. If your check is insufficient to deduct
61
$100
$181
$250
the premiums, we will contact you to make payment
62
$108
$193
$263
arrangements. The chart in the next column shows the monthly
63
$123
$212
$281
premiums for each option.
64
$137
$231
$300
65
$151
$250
$319
66
$166
$269
$338
67
$180
$288
$357
68
$201
$313
$381
69
$222
$339
$404
70
$244
$364
$428
71
$265
$389
$451
72
$286
$414
$475
73
$314
$444
$502
74
$343
$474
$529
75
$371
$503
$556
76
$399
$533
$584
77
$427
$563
$611
78
$471
$609
$654
79
$515
$654
$698
80
$559
$700
$741
81
$603
$746
$784
82
$646
$791
$828
83
$731
$887
$923
84
$815
$982
$1,018
85**
$900
$1,078
$1,113
* and under
** and over
ben051 (Rev. 11/16)
G:\Communications_Only\200 Products\206\Benefits\ben051.indd
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