Form GEN041 "Health Benefits Enrollment/Waiver for Retirees With Same-Sex Partners" - Alaska

What Is Form GEN041?

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 January 1, 2012;
  • The latest edition provided by the Alaska Department of Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form GEN041 by clicking the link below or browse more documents and templates provided by the Alaska Department of Administration.

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Download Form GEN041 "Health Benefits Enrollment/Waiver for Retirees With Same-Sex Partners" - Alaska

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HEALTH BENEFITS ENROLLMENT/WAIVER
FOR OFFICE USE ONLY
For Retirees with Same-Sex Partners
Public Employees’ Retirement System (PERS) Tier I
Teachers’ Retirement System (TRS) Tier I
Judicial Retirement System (JRS)
Elected Public Officers Retirement System (EPORS)
Division of Retirement and Benefits
Juneau: (907) 465-4460
P.O. Box 110203
Toll-Free: (800) 821-2251
TDD: (907) 465-2805
Juneau, Alaska 99811-0203
Fax: (907) 465-3086
alaska.gov/drb
Tier I
PERSONAL DATA
Name
RIN or last 4 of SSN
p PERS p TRS p EPORS p JRS
Please indicate your retirement system:
DENTAL-VISION-AUDIO BENEFITS
I elect the following dental-vision-audio (DVA) coverage:
No dental-vision-audio coverage
p
Individual only
Individual and same-sex partner
p
p
Individual and child(ren)
Individual, same-sex partner, and child(ren)
p
p
LONG-TERM CARE BENEFITS
I elect the following long-term care (LTC) option:
No long-term care coverage
p
Individual (Member) coverage:
Silver
Gold
Platinum
p
p
p
Same-sex Partner coverage (may elect only if member is electing individual coverage):
Same-sex Partner’s Date of Birth _____________
Silver
Gold
Platinum
p
p
p
I am covered under my same-sex partner’s LTC plan Same-sex Partner’s Date of Birth _____________
p
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 insurance elected above.
SIGNATURE
DATE
GEN041 (1/12)
G:/publications/forms/general/gen041.indd
HEALTH BENEFITS ENROLLMENT/WAIVER
FOR OFFICE USE ONLY
For Retirees with Same-Sex Partners
Public Employees’ Retirement System (PERS) Tier I
Teachers’ Retirement System (TRS) Tier I
Judicial Retirement System (JRS)
Elected Public Officers Retirement System (EPORS)
Division of Retirement and Benefits
Juneau: (907) 465-4460
P.O. Box 110203
Toll-Free: (800) 821-2251
TDD: (907) 465-2805
Juneau, Alaska 99811-0203
Fax: (907) 465-3086
alaska.gov/drb
Tier I
PERSONAL DATA
Name
RIN or last 4 of SSN
p PERS p TRS p EPORS p JRS
Please indicate your retirement system:
DENTAL-VISION-AUDIO BENEFITS
I elect the following dental-vision-audio (DVA) coverage:
No dental-vision-audio coverage
p
Individual only
Individual and same-sex partner
p
p
Individual and child(ren)
Individual, same-sex partner, and child(ren)
p
p
LONG-TERM CARE BENEFITS
I elect the following long-term care (LTC) option:
No long-term care coverage
p
Individual (Member) coverage:
Silver
Gold
Platinum
p
p
p
Same-sex Partner coverage (may elect only if member is electing individual coverage):
Same-sex Partner’s Date of Birth _____________
Silver
Gold
Platinum
p
p
p
I am covered under my same-sex partner’s LTC plan Same-sex Partner’s Date of Birth _____________
p
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 insurance elected above.
SIGNATURE
DATE
GEN041 (1/12)
G:/publications/forms/general/gen041.indd
HEALTH BENEFITS ENROLLMENT/WAIVER FORM
For Retirees with Same-Sex Partners
This form is for retirees and other benefit
DVA Coverage for:
Premium
recipients who are members of Elected Public
Individual only
$ 63
Officers Retirement System (EPORS) or Judicial
Individual and same-sex partner
$124
Retirement System (JRS) or who were first hired
Individual and child(ren)
$112
Individual, same-sex partner, and child(ren)
$176
under the Public Employees’ Retirement Sys-
tem (PERS) before July 1, 1986, or under the
Long-Term Care Benefits – Premium Rates By Age
Teachers’ Retirement System (TRS) before July 1,
Age
Silver Option
Gold Option
Platinum Option
1990. This is your opportunity to elect to partici-
$400,000 max
$300,000 max
$300,000 max
at
pate in two separate health plans; dental-vision-
Retirement
No inflation
Simple inflation
Compound inflation
protection
protection
protection
audio (DVA) and long-term care (LTC). You may
40 & under
$26
$76
$148
elect either or both of the insurances offered.
41
$27
$77
$150
You must indicate a choice in both sections even
42
$28
$78
$153
if you are electing not to participate in a certain
43
$30
$79
$155
44
$31
$81
$158
plan.
45
$33
$82
$161
If you are already covered under your same-sex
46
$35
$84
$164
47
$37
$85
$167
partner’ s LTC plan, you cannot be covered under
48
$39
$89
$170
a second plan. Please provide your same-sex
49
$41
$92
$172
partner’ s social security number so we may move
50
$44
$96
$175
your LTC coverage to your retirement benefit.
51
$46
$100
$177
52
$49
$103
$180
Your form must be postmarked or received in our
53
$52
$109
$184
office before your retirement date.
54
$56
$114
$188
55
$60
$120
$192
This is your only opportunity to enroll your
56
$63
$126
$195
same-sex partner in these plans. If you do not
57
$67
$131
$199
enroll at this time, you waive your right to
58
$75
$143
$212
participate in the future.
59
$84
$156
$225
60
$92
$168
$237
You may decrease or terminate your coverage at
61
$100
$181
$250
any time by notifying this office in writing. You
62
$108
$193
$263
63
$123
$212
$281
may only increase DVA coverage within 120 days
64
$137
$231
$300
of the date you become eligible to enroll a same-
65
$151
$250
$319
sex partner under 2 AAC 38.010-38.100, or have
66
$166
$269
$338
your first child. LTC coverage may be added for
67
$180
$288
$357
68
$201
$313
$381
your same-sex partner in the future within 120
69
$222
$339
$404
days of the date you become eligible to enroll a
70
$244
$364
$428
same-sex partner, but is subject to approval by
71
$265
$389
$451
the health claims administrator.
72
$286
$414
$475
73
$314
$444
$502
If you elect coverage, the premiums will be
74
$343
$474
$529
75
$371
$503
$556
deducted from your benefit check each month. If
76
$399
$533
$584
your check is insufficient to deduct the
77
$427
$563
$611
premiums, we will contact you to make payment
78
$471
$609
$654
arrangements. The chart in the next column
79
$515
$654
$698
80
$559
$700
$741
shows the monthly premiums for each option.
81
$603
$746
$784
82
$646
$791
$828
83
$731
$887
$923
84
$815
$982
$1,018
85 & over
$900
$1,078
$1,113
GEN041 (1/12)
G:/publications/forms/general/gen041.indd
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