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Human Resources > Employee and Retiree Benefits > RETIREE Health & Dental > Retiree Applications and Forms

Retiree Applications and Forms

Retiree Health and/or Dental Insurance Applications

Application for the Retired/Disabled Health and Dental Insurance Group 
Cancellation of Retiree Health and/or Dental Insurance


Sick Leave Insurance Program (SLIP)

SLIP Enrollment
SLIP Calculation Estimate
SLIP Retiree Rehire Authorization


Wellmark Applications 

Wellmark State of Iowa Retiree Application 
Wellmark Automatic Payment Authorization


Group MedicareBlue Rx Applications

Iowa Group MedicareBlue Rx Application (for Group Program F or N)  
Iowa Group MedicareBlue Rx Application (for Iowa Choice or National Choice)

MedicareBlue Rx Electronic Funds Transfer (EFT) form


Dental Insurance Application

Delta Dental Insurance Application
Delta Dental's Authorization for Automatic Bank Account Withdrawal


updated 04/08/2021

 

 

 

 

Human Resources

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Human Resources Questions: CustServ.HRE@iowa.gov Hours of Operation: 8:00 a.m. to 4:30 p.m.

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