Health Insurance Forms for Retired Members

Medium

Forms Policy

  1. Digital signatures are not accepted by NDPERS.
  2. Completed forms must be submitted to NDPERS by fax, by mail, or as a scanned PDF.
  3. NDPERS does not accept picture files such as .jpeg, .jpg, .tif, or .png.

Select a form to download:

Enrollment or Cancellation of Coverage

Continuation of Group Insurance Coverage - COBRA
Dakota Plan (Non-Medicare) Enrollment
Dakota Retiree Plan (Medicare) Enrollment
Disenrollment 

Dependent Disability

Access to Communications - Protected Health Information

Other general forms