Retirement Initiation Packet Eligible employees planning to retire in the near future must complete this at least 3 months prior to the selected retirement date. Demographic InformationLegal Name First Middle Last Retirement Date (must be the 1st of a month)* MM slash DD slash YYYY Upload a copy of your Retirement LetterAccepted file types: pdf, doc, docx, Max. file size: 100 MB.Employee Date of Birth MM slash DD slash YYYY Employee Date of Marriage (if married) MM slash DD slash YYYY Employee ID Number (must be 6 digits)* UConn Health Email Address Personal Email Address Telephone Number (work)Telephone Number (home)Telephone Number (cell)Address as of Retirement Date (cannot be a P.O. box) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Retirement PlansCurrent Retirement PlanChoose OneSERS (Tier I, II, IIA, III)HybridAlternate Retirement Plan (ARP)Benefit Payment Option (select one)Option D Straight Life Annuity (no benefits are payable after your death, and health insurance terminates for any dependents enrolled in retiree health insurance.) Option A 50% Spouse (50% of your payment and lifetime retiree health insurance continues after your death to a surviving spouse.) Option B 50% Annuitant – non-spouse (50% of your payment continues after your death to a survivor. Only one annuitant may be selected and can never be changed.) 100% Spouse (100% of your payment and lifetime retiree health insurance continues after your death to a surviving spouse) 100% Annuitant – non-spouse (100% of your payment continues after your death to a survivor. Only one annuitant may be selected and can never be changed.) Option C 10 Year Period Certain (If you pass away within first 10 years of retirement, payments continue to annuitant(s) for balance of 10 year period. Multiple annuitants may be selected.) 20 Year Period Certain (if you pass away within the first 20 years of retirement, payments continue to annuitant(s) for balance of 20 year period. Multiple annuitants may be selected.) Hybrid Cash-out option ANNUITANT INFORMATIONPlease provide the following information for your spouse or annuitant(s).Name First Middle Last Date of Birth MM slash DD slash YYYY RelationshipSelect OneSpouseChildDependentOtherADDITIONAL ANNUITANT INFORMATIONPlease provide the following information for your spouse or annuitant(s).Name First Middle Last Date of Birth MM slash DD slash YYYY Relationship Health Insurance ElectionsIncluding yourself, how many people will be covered on your plan?Select One12345Your Name First Middle Last Date of Birth MM slash DD slash YYYY RelationshipSelect OneSpouseChildSelfMedical CoverageSelect OneYesNoDental CoverageSelect OneYesNoEligible for MedicareSelect OneYesNoName First Middle Last Date of Birth MM slash DD slash YYYY RelationshipSelect OneSpouseChildSelfMedical CoverageSelect OneYesNoDental CoverageSelect OneYesNoEligible for MedicareSelect OneYesNoName First Middle Last Date of Birth MM slash DD slash YYYY RelationshipSelect OneSpouseChildSelfMedical CoverageSelect OneYesNoDental CoverageSelect OneYesNoEligible for MedicareSelect OneYesNoName First Middle Last Date of Birth MM slash DD slash YYYY RelationshipSelect OneSpouseChildSelfMedical CoverageSelect OneYesNoDental CoverageSelect OneYesNoEligible for MedicareSelect OneYesNoName First Middle Last Date of Birth MM slash DD slash YYYY RelationshipSelect OneSpouseChildSelfMedical CoverageSelect OneYesNoDental CoverageSelect OneYesNoEligible for MedicareSelect OneYesNoRetiree Health Medical Plan Election for Non-Medicare Eligible Retirees and/or DependentsSelect one of the options below Anthem Primary Care Access [POE-G Plus] Anthem Standard Access [POE] Anthem Quality First Select Access [Prime Plus/Tiered POS] Anthem Expanded Access [POS] Anthem State Preferred POS – Currently Enrolled Only Anthem Out of Area Plan – Only if Retiree’s Permanent Residence is Outside of Connecticut Waive Medical Coverage Retiree Dental PlanSelect one of the options below Basic Dental Plan Enhanced PPO Dental Plan Dental HMO Plan Waive Dental Coverage CAPTCHAUpon receipt of your request, Human Resources will verify your eligibility to retire on your requested date, and will provide you with a checklist to complete the remaining steps of the retirement process. Please submit this form by clicking the SUBMIT button below.CommentsThis field is for validation purposes and should be left unchanged.