AlaskaCare Retiree Forms

Enrollment Forms

Tier I Health Benefits Enrollment/Waiver form ben051
Health Benefits Enrollment/Waiver for Retirees or Benefit Recipients [PDF]
Tier I employees: Elect or waive health plan participation, either dental-vision-audio (DVA) and/or long-term care (LTC). You must indicate a choice in both sections even if you are electing not to participate in a certain plan.
Tier II & III Health Benefits Enrollment/Waiver form ben035
Health Benefits Enrollment/Waiver for Retirees or Benefit Recipients [PDF]
Tier II & III employees: Elect or waive health plan participation, either dental-vision-audio (DVA) and/or long-term care (LTC). You must indicate a choice in both sections even if you are electing not to participate in a certain plan.
Retiree Health Dependent Change form 02-1854r
Retiree Health Dependent Change Form [PDF]
Use this form to list dependents to be added or removed due to marriage, divorce, birth, same-sex partnership, death or adoption.