Life Insurance Forms for Retired Members

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 and Designation of Beneficiary

• Retiree Life Insurance Application (SFN 53622)
• Life Insurance Designation of Beneficiary (SFN 53855)

Conversion and Portability (Continuation)

• Life Conversion Information Request
• Term Life Coverage Continuation Request and portability rates
• Understand Conversion and Portability 

Other general forms

• Authorization for Automatic Premium Deduction (SFN 50134)
• Authorization to Release Confidential Information (SFN 61324)
• Notice of Change - For Name & Address (SFN 10766)