Online Enrollment Form × Add New Dependent First Name Last Name Gender Male Female B-Day Relationship Wife Husband Child Enrollment Type Enroll Change Cancel Tobacco User Yes No Other Insurance SSN No Cancel Add Dependent × Select Dependent Profile Coverage ID Theft Protection Critical Illness Accident Life Dental Vision Confirmation First Name* Middle Initial Last Name* Social Security No* Address* Address 2 City* State* North Carolina Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP* Date of Birth Phone* Date of Retirement* Email* Marital Status Single Married Gender* Male Female ID Theft Protection Premium Information Every 2 seconds someone is a victim of identity theft. LifeLock offers 3 layers of identity theft protection: Detect Alert Restore Critical Illness Premium Information Guaranteed Issue coverage, meaning no medical questions to answer at initial enrollment for retiree, spouse and child(ren) Benefits are paid to you Covers heart attack, cancer, stroke and more Accident Premium Information $50 or $75 physician visit twice per year for any reason Cash benefits are paid directly to you, unless assigned Life Premium Information Long term care and terminal illness riders available Coverage available for: self, spouse, children and grandchildren Dental Premium Information Visit any dentist or dental specialist of your choice No waiting period Vision Premium Information Visit Any In-Network provider of your choice No waiting period Identity Theft Protection: LifeLock Premium Information Every 2 seconds someone is a victim of identity theft. LifeLock offers 3 layers of identity theft protection: Detect Alert Restore Plan Coverage Retiree Retiree+1 Retiree+Family Enrollment Type Enroll Change Cancel Additional Information you need us to be aware of: LifeLock Dependents New Dependent Add Existing Dependent Critical Illness: Allstate Premium Information Guaranteed Issue coverage, meaning no medical questions to answer at initial enrollment for retiree, spouse and child(ren) Benefits are paid direct to you Covers heart attack, cancer, stroke and more Plan Coverage Retiree Retiree+1 Retiree+Family Enrollment Type Enroll Change Cancel Tobacco User? YES NO Additional Information you need us to be aware of: Beneficiary Name Relationship to Insured Spouse Child Sibling Other Critical Illness Dependents New Dependent If you would like Accident coverage, return to the Coverage section and select it. If not, please click the Continue button below. Accident: Allstate Premium Information $50 or $75 physician visit twice per year for any reason including sickness Cash benefits are paid directly to you, unless assigned Plan Coverage Retiree Retiree+Spouse Retiree+Child(ren) Retiree+Family Enrollment Type Enroll Change Cancel Additional Information you need us to be aware of: Plan Type Low High Beneficiary Name Relationship to Insured Spouse Child Sibling Other Accident Dependents New Dependent Add Existing Dependent Life: Fidelity / Combined Premium Information Guaranteed premiums Life Insurance with money for long-term care Family coverage available: spouse, children and grandchildren For a custom quote call 855-627-3847 or a Benefit Counselor will contact you. If you would like Dental coverage, return to the Coverage section and select it. If not, please click the Continue button below. Dental: UnitedHealthcare Premium Information Visit any dentist or dental specialist of your choice No waiting period Plan Coverage Retiree Retiree+1 Retiree+Family Enrollment Type Enroll Change Cancel Additional Information you need us to be aware of: Dental Dependents New Dependent Add Existing Dependent Vision: UnitedHealthcare Premium Information Visit Any in-network provider of your choice You may have your eye exam at one location and take your prescription to an in-network retailer to fill No waiting period Plan Coverage Retiree Retiree+1 Retiree+Family Enrollment Type Enroll Change Cancel Additional Information you need us to be aware of: Vision Plan Plan 1 - Exam & Material Coverage Plan 2 - Materials Only Coverage Vision Dependents New Dependent Add Existing Dependent Profile ID Theft Protection Review Critical Illness Review Accident Review Life Review Dental Review Vision Review Payment Options Pension Deduction Authorization I hereby authorize the North Carolina Retirement Systems to deduct my identify theft, critical illness, accident, dental and/or vision premiums from my retirement benefit. To the best of my knowledge, I confirm that the information I have provided on this form is complete and accurate. Firefighters and Rescue Squad Workers, National Guard or Register of Deeds Pension Funds' benefit recipient do not qualify for pension deduction. Direct Bill Option Please place the benefits that I have applied for on direct bill. Firefighters and Rescue Squad Workers, National Guard or Register of Deeds Pension Funds' recipient do not qualify for a pension deduction Please select the Direct Bill option. LIFELOCK: PREAUTHORIZED PAYMENT AUTHORIZATION As a convenience to me, I authorize LifeLock to make electronic debits or other forms of preauthorized withdrawals from my financial institution as indicated below. I understand that if a debit or withdrawal is not honored by the financial institution, LifeLock will consider the premium unpaid. Any debit or withdrawal returned due to insufficient funds may be re -deposited by LifeLock at its sole discretion. This authorization will remain in effect until written notice by the depositor/card holder is received by LifeLock. Draft will occur on the 15th of each month. I further agree that if any such debit or withdrawal is not honored, whether with or without cause, LifeLock shall be under no liability whatsoever even though such dishonor results in the lapse of insurance. Check here if you agree Bank Name Routing Number Account Number Your Name Last 4 of SSN Date Terms & Conditions If you would like to review what you are submitting, cycle through the different tabs above to check your work. When you are ready, click the Submit button below Terms and Conditions I confirm that the information I have provided on this form is complete and accurate. Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application containing false, incomplete or misleading information may be prosecuted as allowed by appropriate state law. I hereby authorize the North Carolina Retirement System to deduct my dental, vision and/or accident plan premiums from my retirement benefit period. By Checking the box below, I authorize Pierce Insurance to use my information as reasonably needed to obtain the elected insurance option. The form and the acceptance of terms and conditions will act as the signed document, however Pierce Insurance may request a written signature later if needed. Check Here to accept terms and conditions Previous Next × …
