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, death or adoption.