Online Enrollment Form

Pension Deduction Authorization I hereby authorize the North Carolina Retirement Systems to deduct my 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. Please select "Direct Bill" option below.

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.

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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.