Change Amount of Life Insurance

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Change Amount

Coverage Change Type Coverage Decrease Coverage Increase Losing Retiree Life Add Coverage

Decrease Coverage

Retiree Options

Spouse/Domestic Partner Options

Child(ren) Options

Effective Date

Increase Coverage

Retiree Options

Spouse/Domestic Partner Options

Child(ren) Options

Download the Life Insurance Medical History Statement

Losing Retiree Life - Due to age

Losing Retiree Life coverage from New Mexico Public Schools Insurance Authority (NMPSIA) due to age:
With proof of life insurance amounts lost from NMSPIA and enrolling within 31 days of the loss you may enroll up to the insurance amounts lost.

Retiree Options

Spouse/Domestic Partner Options

Child(ren) Options

Effective Date

Add Coverage

Retiree Options

Spouse/Domestic Partner Options

Child(ren) Options

Download the Life Insurance Medical History Statement

Documents

Evidence of Insurability Statement

Life Insurance Medical History Statement

Declaration and Signature

By selecting the boxes below, I acknowledge that:

Participation in the New Mexico Retiree Health Care Act is subject to specific eligibility requirements and that benefits offered through the New Mexico Retiree Health Care Authority are subject to legal limitations. Ineligible individuals cannot receive benefits through this program and will benefits or services will not exceed legal limitations. Submitting information on this page is only an application for benefits and does not create any contractual relationship or impose any duties on the part of the New Mexico Retiree Health Care Authority. I must comply with all program requirements, including making timely payments, to enroll and participate. I agree that the New Mexico Retiree Health Care Authority may terminate my participation in this program for noncompliance. I have carefully read and understood all statements on this page and included with this submission, approve all indicated changes, and elect the coverages and benefits selected. I am the actual person applying for benefits whose signature appears below or I am signing on another's behalf under a power of attorney. (If I am signing on another's behalf under a power of attorney, I have attached current authorizing documents or ensured that the New Mexico Retiree Health Care Authority has current authorizing documents on file.)

By typing my name in the space provided below, I hereby declare that all the information I have provided in connection with this application is true and complete to the best of my knowledge.

Type full name in the box below

Today's Date

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