THINKING OF RETIRING?

Transcription

1 33 Plaza La Prensa, Santa Fe, New Mexico (505) fax (505) voice (800) Toll-Free PERA INFORMATION SHEET THINKING OF RETIRING? If you are considering retiring, PERA requests that you submit the following documents to us at least sixty (60) calendar days in advance of your anticipated retirement date: Application for Pension Form Copy of a birth or baptismal certificate for yourself PERA Tax Deduction Form Copy of a birth or baptismal certificate for your beneficiary PERA Spousal Consent Form (if married) Copy of your marriage certificate (if applicable) PERA Affirmation of Marital Status Form (if not married at the Court endorsed copies of all divorce decrees and time of retirement) marital settlement agreements (if applicable) PERA Direct Deposit Authorization Form (mandatory) Your beneficiary's social security number on the Application for Pension Form Please write your name and social security number or PERA ID number on ALL of the forms and copies of documents. If you have applied for retirement and have ALREADY submitted the required documentation, you DO NOT have to submit the documentation again. Remember that we cannot process your retirement benefits without receiving the completed forms listed above. If we do not receive your application and all the required information prior to your selected retirement date, your retirement date will be postponed until the first of the month following our receipt of all completed required forms. WHEN IS YOUR RETIREMENT EFFECTIVE? Your Retirement becomes effective the First Day of the Month Following: Receipt of your completed application and all required supporting documentation Termination of your employment with your current PERA employer Determination by PERA that you have successfully met all eligibility requirements and conditions for retirement PERA will request an Employer's Certification from your current employer verifying your last date of employment and a report of your last month's earnings and contributions. When PERA has received all the completed documentation, we will authorize your benefit payments on the State payroll system. You should receive your first by direct deposit on the last working day of your retirement month. WHEN ARE YOUR BENEFITS PAID? PERA retirement benefits are paid once a month on the last working day of each month. Your benefit payments will be electronically transferred on the last business day of each month to the financial institution selected on your PERA Direct Deposit Authorization Form. Direct deposit of benefit payments is mandatory. WHAT ABOUT ANY CHANGES PRIOR TO YOUR EFFECTIVE RETIREMENT DATE? You must notify PERA in writing of any changes in your status prior to your effective retirement date. Failure to do so may result in a payment delay of your benefit. Notify PERA Member Services in writing at the address at the top of the page. Be sure to include your social security number or PERA ID number, your telephone number and your current address on all correspondence. IMPORTANT! If you chose your spouse as your beneficiary and your spouse dies after you retire or you are divorced, your pension will be changed to Form of Payment A. You are eligible to choose another beneficiary in the case of a divorce or death of your beneficiary. Retirees who name a beneficiary other than their spouse at the time of retirement have a one-time irrevocable option to change their beneficiary under the same form of payment or move up to Form of Payment A. Please contact PERA if you need additional information about this option. OTHER IMPORTANT Health Insurance Deferred Compensation CONTACTS: NM Retiree Healthcare Authority Program Manager, PERA Deferred Compensation 4308 Carlisle Blvd, NE Suite Plaza La Prensa Albuquerque, NM Santa Fe, NM (800) or (505) (800) or (505) September 2015

2 33 Plaza La Prensa, Santa Fe, New Mexico (505) fax (505) voice (800) Toll-Free APPLICATION FOR PENSION FORM Instructions: Please print or type in a dark ink. The original of this form must be completed in its entirety and returned to PERA for processing. Required fields are in BOLD ITALICS GENERAL INFORMATION PLEASE TYPE OR PRINT CLEARLY SOCIAL SECURITY NUMBER or PERA ID NUMBER NAME FIRST MI LAST MAILING ADDRESS CITY STATE ZIP MARITAL STATUS NEVER MARRIED MARRIED DIVORCED WIDOWED HAVE YOU BEEN DIVORCED? Yes No If yes, please provide court endorsed copies of your divorce decree and property settlement agreement(s) that happened while a PERA member. If the divorce happened prior to PERA membership and you have not remarried, provide a copy of only the divorce decree. If you remarried prior to PERA membership and are still married to the same person, you do not need to provide any divorce documentation. DO YOU HAVE SERVICE CREDIT IN ANY OF THESE PLANS? PERA ERB MRA JRA VFF Legislative LAST PERA AFFILIATED EMPLOYER EFFECTIVE TERMINATION DATE Date you leave/left employment DATE OF BIRTH PLANNED RETIREMENT DATE First day of a month BENEFICIARY DESIGNATION AND FORM OF PAYMENT Upon retirement, you may select ONE of the following forms of payment of a pension. PERA will provide you with an estimate of your benefits as requested below. Form of Payment A: Straight Life Option. Provides a benefit to you for your lifetime. Payments stop upon your death. Form of Payment B: Joint Survivor Option (100%). Provides a benefit to you for your lifetime with the same amount continuing for life to your beneficiary upon your death. Form of Payment C: Joint Survivor Option (50%). Provides a benefit to you for your lifetime with 50% of that amount continuing for life to you beneficiary upon your death. Form of Payment D: Temporary Joint Survivor Option (Children). Provides a benefit to you for life, with the same amount continuing to your eligible children until each child reaches age 25. Provide beneficiary information for each child. Magistrate - Judicial - Volunteer Firefighter: Survivor pension paid according to each specific statute. BENEFICIARY SELECTION If you chose Form of Payment A: Please name a refund beneficiary or organization below. Upon your death, if the total amount of payments received is less than your total employee contributions, the difference will be refunded to your refund beneficiary or organization specified below. If no refund beneficiary designation is on record, any employee contributions will be refunded to your estate. If you choose Form of Payment B, C or D: please give us the full name, address, date of birth and relationship. If you are married on the date of your retirement and do not name your spouse as survivor beneficiary, your spouse must consent in writing. You must submit proof of age on yourself and your survivor beneficiary as well as marriage certificates or divorce decrees and property settlement agreements. If Form of Payment D is desired, you must provide proof of age on each child under the age of 25. FORM OF PAYMENT A ONLY ORGANIZATION AS A REFUND BENEFICIARY Organization Name Address/Phone Number Organization Tax ID Number PERSON AS A REFUND OR SURVIVOR BENEFICIARY FORM OF PAYMENT A, B, C & D. For Form of Payment D provide beneficiary information for each child. FIRST MI LAST Name Relationship Mailing Address City State Zip Beneficiary s Social Security Number Date of Birth CONTINUED ON PAGE 2 September 2015

3 Page 2 Application for Pension PLEASE TYPE OR PRINT CLEARLY MEMBER INFORMATION SOCIAL SECURITY NUMBER or PERA ID NUMBER NAME FIRST MI LAST APPLICANT'S STATEMENT I do hereby apply for retirement benefits as indicated Applicant Print Name above. I understand my retirement benefits will begin the first of the month following the completion of all the following: 1) my meeting the age and service requirements for normal retirement; 2) the filing of this form; 3) termination of all employment under, Judicial, Magistrate and Educational Retirement. I also understand that should I ever return to employment with an employer under PERA, JRA or MRA, I must contact PERA and my pension might be subject to suspension. I certify that the information contained herein is true and correct to the best of my knowledge. APPLICANT'S SIGNATURE HOME OR CELL NUMBER DATE Any changes to the information you are providing for your retirement must be done in writing. If you are changing your retirement date, send PERA notification in writing with your name, ID number, your original retirement date and the new effective retirement date. If you are changing your beneficiary or Form of Payment option, you must complete a new Application for Pension Form, provide a copy of proof of age for the new beneficiary and if you are married, provide a new Spousal Consent Form. PERA requests completed retirement applications be submitted sixty (60) calendar days prior to your expected retirement date but no sooner than 1 year. After you submit your retirement paperwork, PERA will mail you an acknowledgement letter either stating your application is complete or something is either missing or incomplete. The letter for the missing or incomplete information will be mailed to you as a certified letter. Once PERA has received all missing or completed information, an acknowledgement letter will be mailed to you. The next correspondence from PERA will be about your first benefit payment. You should receive your first benefit payment as a direct deposit the last working day of the month you retire in. For example: if your retirement date is January 1, you will receive the January benefit payment as a direct deposit on the last working day of January. NOTE: If you have reciprocity with ERA, your first benefit payment will be delayed for up to 6 weeks from your retirement date. If you have any questions about the retirement process call Plaza La Prensa, Santa Fe, New Mexico (505) fax (505) voice (800) Toll-Free September 2015

4 33 Plaza La Prensa, Santa Fe, New Mexico (505) fax (505) voice (800) Toll-Free AFFIRMATION OF MARITAL STATUS FORM This form affirms to PERA you are not currently married. If you are married at the time of retirement, complete a Spousal Consent Form. Instructions: Please print or type in dark ink. The original of this form must be completed in its entirety and returned to PERA for processing. Required fields are in BOLD ITALICS. No correction fluid will be allowed on this form. GENERAL INFORMATION PLEASE TYPE OR PRINT CLEARLY SOCIAL SECURITY NUMBER or PERA ID NUMBER FIRST NAME MI LAST NAME MAILING ADDRESS CITY STATE ZIP HOME or CELL TELEPHONE NO. DATE OF BIRTH MARITAL STATUS NEVER MARRIED MARRIED DIVORCED WIDOWED HAVE YOU BEEN DIVORCED? Yes No If yes, please provide court endorsed copies of your divorce decree and property settlement agreement(s) that happened while a PERA member. If the divorce happened prior to PERA membership and you have not remarried, provide a copy of only the divorce decree. If you remarried prior to PERA membership and are still married to the same person, you do not need to provide any divorce documentation. I,, an applicant for PERA pension benefits, affirm that I am not currently legally married. This does not include a legal separation. DATE SIGNATURE OF RETIREE in the presence of a notary PERA Rule B(3)NMAC requires that the retiring member provides PERA with court endorsed copies of all divorce orders and marital settlement agreements entered after the first PERA membership application is filed, if the member has been previously married. To ensure that the member receives a pension for the retirement date chosen, the completed retirement application should be returned to PERA with all required documents at least 60 days prior to retirement. The completed application and supporting documentation must be filed with PERA no later than the close of business on the last working day of the month prior to the selected date of retirement in accordance A(1)NMAC. NOTARIZATION OF RETIREE S SIGNATURE Retiree s Signature Must be Done In The Presence Of A Notary State of New Mexico ) ) SS: County of ) Signed and sworn to (or affirmed) before me by on this the day of,. My Commission Expires Notary Public Telephone No - - Notary Signature No correction fluid will be allowed on this form. September 2015

5 SPOUSAL CONSENT FORM 33 Plaza La Prensa, Santa Fe, New Mexico (505) fax (505) voice (800) Toll-Free Instructions: Please print or type in dark ink. The original of this form must be completed in its entirety and returned to PERA for processing. Required Fields are in BOLD ITALICS. Additional instructions are on the back. No correction fluid will be allowed on this form. SPOUSE S INFORMATION AND NOTARIZATION In The Presence Of A Notary I,, spouse of (Spouse s Name) (please print) consent to his/her decision to receive (Retiree s Name) (please print) benefits under Form of Payment with named as survivor beneficiary. (Beneficiary s Name) (please print) I understand that I will not be entitled to survivor benefits unless I have been listed on the Final Application for Annuity as the beneficiary under either Form of Payment B or C. Date State of New Mexico ) ) SS: County of ) Signature of Retiree s Spouse Signed and sworn to (or affirmed) before me by on this the day of (Spouse s Name) (please print),. My Commission Expires Notary Public Telephone No - - NOTARIZATION OF RETIREE S SIGNATURE In The Presence Of A Notary Signature of Retiree Retiree Name (please print) State of New Mexico ) ) SS: County of ) Notary Signature Retiree s Social Security Number or PERA ID Number Date Signed and sworn to (or affirmed) before me by on this the day of (Retiree s Name) (please print),. My Commission Expires Notary Public Telephone No - - Notary Signature Instructions on back PERA Rule B (3)NMAC requires that the retiring member provides PERA with court endorsed copies of all divorce orders and marital settlement agreements entered after the first PERA membership application is filed. The member should return the completed Application for Pension with all required documentation to PERA at least sixty (60) calendar days prior to the selected date of retirement. If the member does not specify a form of payment prior to their retirement date, the retirement application will be processed according to NMSA 1978, Section A(1)(2004). This section of the state statute requires payment to be made under Form of Payment A if there is no eligible spouse or under Form of Payment C if there is an eligible spouse. If payments are to be made under Form of Payment C according to this section, the eligible spouse will be designated as the survivor beneficiary. No correction fluid will be allowed on this form. September 2015

6 INSTRUCTIONS FOR COMPLETING THE SPOUSAL CONSENT FORM No correction fluid will be allowed on this form. Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Step 9 The retiree s spouse must complete, date and sign this document in the Spouse s Information and Notarization section in front of a notary public. Your spouse prints his/her name in the first space designated spouse s name. Your spouse prints your name in the second space designated retiree s name. Your spouse prints the Form of Payment option that has been agreed upon in the third space after Form of Payment. Your spouse prints the name of the agreed upon beneficiary in the space designated beneficiary s name, even if your spouse is the beneficiary. This blank must be filled in even if selecting Form of Payment A. If you desire to name no one as a beneficiary, PERA will accept language such as no one or n/a. If no beneficiary is named, member contribution balances will be paid to the retiree s estate upon death. Your spouse must sign and date this document in front of a notary public. The following must be filled in by the notary public: The notary public must write down in which county they are signing the document. The notary must print your spouse s name in the space designated spouse s name. The notary must fill out the complete date. The notary must fill in his/her term expiration date. The notary must either imprint or stamp this document. The notary must sign his/her name in the space designated Notary Signature. The retiree must sign and date this document in the Notarization of Retiree s Signature section in front of a notary public. The following must be filled in by the notary public: The notary public must write down in which county they are signing the document. The notary must print the retiree s name in the space designated retiree s name. The notary must fill out the complete date. The notary must fill in his/her term expiration date. The notary must either imprint or stamp this document. The notary must sign his/her name in the space designated Notary Signature.

7 33 Plaza La Prensa, Santa Fe, New Mexico (505) fax (505) voice (800) Toll-Free PERA DIRECT DEPOSIT AUTHORIZATION FORM Instructions: Please print or type in dark ink. The original of this form must be completed in its entirety and returned to PERA for processing. Required Fields are in BOLD ITALICS. Additional instructions are on the back page. Check One: New SOCIAL SECURITY NUMBER or PERA ID NUMBER Change In Existing Information NAME First Middle Initial Last MAILING ADDRESS City State Zip Code TELEPHONE or CELLULAR NUMBER FINANCIAL INSTITUTION NAME ACCOUNT NUMBER (only one) Check One PERA cannot split a direct deposit. Savings or Checking I authorize PERA to make credit and debit entries to my account at the above named financial institution. I agree to notify PERA immediately upon discovery of any errors resulting from transactions under this authorization and of any changes that may affect these instructions. I agree to hold PERA and the State of New Mexico harmless from any and all loss, cost, damage or expenses suffered as a result of errors in credit or debit entries caused by persons not employed by PERA. I direct the above named financial institution to refund to PERA any deposits made to my account after my death in accordance with the agreement set forth below. SIGNATURE OF BENEFIT RECIPIENT DATE FINANCIAL INSTITUTION CERTIFICATION Agreement of Depository Financial Institution In accordance with the authorization of the depositor, we hereby agree to credit and debit to depositor s account, benefit payments and corrections made by the New Mexico Public Employees Retirement Association without depositor s endorsement. We further agree to repay and refund to PERA on demand, the total amount of any such payments received and deposited to the account of the depositor, the due date of which occurs subsequent to the death of the depositor, and agree to accept the certification of PERA as sufficient evidence of the date of death of the depositor. By signature hereon we have verified the account number of the depositor. FINANCIAL INSTITUTION ROUTING NUMBER ONLY NAME OF FINANCIAL INSTITUTION MAILING ADDRESS BUSINESS TELEPHONE NUMBER Must be a 9 digit number FINANCIAL INSTITUTION REPRESENTATIVE SIGNATURE ATTACH A VOIDED CHECK OR DEPOSIT SLIP HERE (used to verify your financial institution account number) September 2015

8 INSTRUCTIONS FOR COMPLETING THE PERA DIRECT DEPOSIT AUTHORIZATION FORM Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Check New if this is the first time you are filling out this form. Check Change In Existing Information if you are changing existing information you have already provided PERA. Print or type your First Name, Middle Initial and Last Name. Print or type your Social Security Number and or your PERA ID Number. Print or type your Address, City, State and Zip Code. Print or type your telephone or cellular number. Print or type the name of your bank or financial institution. Print or type your account number you want your benefit payment to be direct deposited into. You may only have one account for your direct deposit. Check either box for the type of account. (Checking or Savings) Sign and date the document. Take the PERA Direct Deposit Authorization Form to your financial institution. Have a representative from your financial institution prepare the Financial Institution Certification at the bottom of the form and verify your account number. The authorized financial institution representative must provide the following: Financial Institution Routing Number Name of the Financial Institution Mailing Address Business Telephone Number Authorized Financial Institution Representative s Signature Attach a voided check or deposit slip. (This will be used to verify the account number.) After you have completed steps 1 through 5, please return or mail the original PERA Direct Deposit Authorization Form to PERA by the fifteenth (15 th ) of the month. If the PERA Direct Deposit Authorization Form is received after the fifteenth (15 th ) of the month, the change to your direct deposit information will take effect the following month.

9 33 Plaza La Prensa, Santa Fe, New Mexico (505) fax (505) voice (800) Toll-Free PERA TAX DEDUCTION FORM Instructions: Please print or type in dark ink. The original of this form must be completed in its entirety and returned to PERA for processing. Required Fields are in BOLD ITALICS. Additional instructions are on the back page. Check One: New Change In Existing Information SOCIAL SECURITY NUMBER or PERA ID NUMBER NAME First Middle Initial Last MAILING ADDRESS City State Zip Code TELEPHONE or CELLULAR NUMBER CHECK ONLY THE APPLICABLE BOXES Do not deduct federal withholding tax from my benefits. Do not deduct New Mexico state withholding tax from my benefits. (If you are living out-of-state, please check this box. PERA cannot withhold other States income taxes.) I realize that I am liable for payment of federal and state income tax on the taxable portion of my pension and that I may be subject to tax penalties under the estimated tax payment rules if my payments of estimated tax withholdings are not adequate. The following exemptions are being claimed, and I want PERA to determine the amount, if any, of federal/new Mexico state income tax to be withheld in accordance with the tax tables and exemptions claimed below: Married rate Single rate Exemptions claimed: 1 for yourself 1 for your spouse 1 if you are 65 or older 1 if your spouse is 65 or older 1 if you are blind 1 if your spouse is blind Other Total exemptions claimed In addition to the withholding on my exemptions, I want the following additional amount withheld from each monthly payment Federal Tax $ New Mexico State Tax $ Instead of withholding based on exemption, I want the following amount withheld from each monthly payment. Federal Tax $ New Mexico State Tax $ AUTHORIZATION I submit this PERA Tax Deduction Form specifying what deductions I authorize to be made from my PERA retirement benefit for federal and New Mexico state income tax purposes. SIGNED DATE September 2015

10 DIRECTIONS FOR THE PERA TAX DEDUCTION FORM Anytime a PERA pension recipient needs to change their tax withholding information with PERA, they must complete this form. The pension recipient must complete the top portion of the form with their personal information. The first box indicates you do not want United States federal income tax withheld from your PERA pension payment. The second box indicates you do not want New Mexico State income taxes withheld from your PERA pension payment. If you move outside the state of New Mexico, you should complete a new PERA Tax Deduction Form and check this box. PERA can only pay New Mexico state income tax. If you move to a state that has an income tax, you must pay this income tax on your own. The third box indicates you want PERA to withhold state and federal income taxes based on a specific number of exemptions at either the married or single rate. The more exemptions you claim will lower the amount the taxes that will be withheld from your check. PERA uses the most current state and federal tax rates. These rates generally change as of January 1 of each year. Even if you do not change your tax withholdings, the amount withheld from your pension payment might change due to a change in the tax rate. Indicate on the line Total Exemptions Claimed the number of exemptions you want your withholdings calculated. The fourth box tells PERA that in additional to the taxes being withheld based on a specific number of exceptions, you wish to have an additional amount withheld. Indicate the additional amount you want for federal taxes and/or state taxes. The fifth box tells PERA that you want an exact amount withheld for your taxes. This amount will not change even if the tax rate changes.

11 NMRHCA Medical Plan Monthly Premium Contributions for January 1, December 31, 2016 (applicable if retirement date is after June 30, 2001) Years of Service NON-MEDICARE MEDICAL Premier Plus (BCBS or Presbyterian) Retiree Rate $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Spouse Rate $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Child Rate* $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Premier (BCBS or Presbyterian) Retiree Rate $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Spouse Rate $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Child Rate* $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ MEDICARE MEDICAL BCBS Medicare Supplemental Plan Retiree Rate $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Spouse Rate $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Child Rate* $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BCBS Medicare Advantage I Retiree Rate $ $ $ $ $ $99.45 $95.63 $91.80 $87.98 $84.15 $80.33 $76.50 $72.68 $68.85 $65.03 $61.20 Spouse Rate $ $ $ $ $ $ $ $ $ $ $ $99.45 $97.54 $95.63 $93.71 $91.80 Child Rate* $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BCBS Medicare Advantage II Retiree Rate $34.58 $33.47 $32.35 $31.24 $30.12 $29.01 $27.89 $26.78 $25.66 $24.54 $23.43 $22.31 $21.20 $20.08 $18.97 $17.85 Spouse Rate $35.14 $34.58 $34.03 $33.47 $32.91 $32.35 $31.79 $31.24 $30.68 $30.12 $29.56 $29.00 $28.44 $27.89 $27.33 $26.77 Child Rate* $35.70 $35.70 $35.70 $35.70 $35.70 $35.70 $35.70 $35.70 $35.70 $35.70 $35.70 $35.70 $35.70 $35.70 $35.70 $35.70 Presbyterian Medicare Advantage I Retiree Rate $ $ $ $ $ $ $ $ $ $ $ $ $99.75 $94.50 $89.25 $84.00 Spouse Rate $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Child Rate* $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Presbyterian Medicare Advantage II Retiree Rate $ $ $97.88 $94.50 $91.13 $87.75 $84.38 $81.00 $77.63 $74.25 $70.88 $67.50 $64.13 $60.75 $57.38 $54.00 Spouse Rate $ $ $ $ $99.56 $97.88 $96.19 $94.50 $92.81 $91.13 $89.44 $87.75 $86.06 $84.38 $82.69 $81.00 Child Rate* $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ United Healthcare Medicare Advantage I Retiree Rate $ $ $ $ $ $ $ $ $ $ $ $ $ $99.56 $94.03 $88.50 Spouse Rate $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Child Rate* $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ United Heathcare Medicare Advantage II Retiree Rate $89.96 $87.06 $84.15 $81.25 $78.35 $75.45 $72.55 $69.65 $66.74 $63.84 $60.94 $58.04 $55.14 $52.23 $49.33 $46.43 Spouse Rate $91.41 $89.96 $88.51 $87.06 $85.60 $84.15 $82.70 $81.25 $79.80 $78.35 $76.90 $75.45 $73.99 $72.54 $71.09 $69.64 Child Rate* $92.86 $92.86 $92.86 $92.86 $92.86 $92.86 $92.86 $92.86 $92.86 $92.86 $92.86 $92.86 $92.86 $92.86 $92.86 $92.86 *Multiple Child Subsidy may apply.

12 Medical Plan Rate Calculation Instructions 1. Select a medical plan for the retiree; enter the rate from the Retiree Rate row that corresponds with your years of service. 2. If you are enrolling your spouse, select a medical plan for him/her; enter the rate from the Spouse Rate row that corresponds with your years of service (or, if your spouse is also an NMRHCA-eligible retiree, use the Retiree Rate that corresponds with your spouse s years of service). 3. If you are also enrolling children, enter rate from Child Rate row once for the first child. For each additional child, enter the Child Rate multiplied by (# of additional children: x Child Rate: x = Total for Additional Child(ren): If multiple children are to be covered without a spouse, please contact NMRHCA for assistance with calculating the rate. $ Retiree + $ Spouse + $ 1 st Child + $ Additional Child(ren) 4. TOTAL #1, #2, and #3. Voluntary Coverage Premiums DENTAL PLAN Monthly Premium*: Effective January 1, 2016 to June 30, 2016 = $ Total SINGLE TWO-PARTY FAMILY Delta Dental Basic $17.85 $33.48 for both $ for all Delta Dental Comprehensive $39.85 $75.72 for both $ for all United Concordia Basic $17.49 $33.23 for both $ for all United Concordia Comprehensive $35.70 $67.82 for both $ for all VISION PLAN Monthly Premium*: Effective January 1, 2016 to June 30, 2016 Davis Vision $ 4.76 $ 8.98 for both $13.23 for all DEPENDENT CHILD LIFE Monthly Premium*: Effective January 1, 2008 to December 31, 2016 The Standard Insurance $2,500 - $3.83 for all $5,000 - $7.15 for all $10,000 - $13.83 for all RETIREE/SPOUSE SUPPLEMENTAL LIFE Monthly Premium*: Effective January 1, 2008 to December 31, 2016 The Standard $2,000 $4,000 $6,000 $8,000 $10,000 $15,000** $20,000** $40,000** $46,000** $60,000** Age $ 0.68 $ 0.86 $ 1.05 $ 1.23 $ 1.41 $ 1.87 $ 2.32 $ 4.14 $ 4.69 $ 5.96 Age $ 0.79 $ 1.08 $ 1.38 $ 1.67 $ 1.96 $ 2.69 $ 3.42 $ 6.34 $ 7.22 $ 9.26 Age $ 1.03 $ 1.56 $ 2.08 $ 2.61 $ 3.14 $ 4.46 $ 5.78 $ $ $ Age $ 1.36 $ 2.22 $ 3.07 $ 3.93 $ 4.79 $ 6.94 $ 9.08 $ $ $ Age $ 1.92 $ 3.34 $ 4.77 $ 6.19 $ 7.61 $11.17 $14.72 $ $ $ Age $ 2.23 $ 3.96 $ 5.70 $ 7.43 $ 9.16 $13.49 $17.82 $ $ $ Age $ 4.05 $ 7.61 $11.16 $14.72 $18.27 $27.16 $36.04 $ $ $ Age 70 and over $ 5.95 $11.40 $16.85 $22.30 $27.75 $41.38 $55.00 $ $ $ *The life plan rates include a $.50 administration fee. This is optional coverage, and the entire cost of coverage is paid by you. Cost of insurance for all coverages paid by you may increase or decrease in the future based upon the claims experience of participants. All provisions that apply to this coverage are governed by the Certificate. **Evidence of Insurability Statement required to add or increase life insurance. The form can be found at