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Retiree Applications & 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 

State of Iowa Group Retiree Application (use for Iowa Choice, National Choice, Group Program F, and Group Program N)
Wellmark Automatic Payment Authorization

Group MedicareBlue Rx Applications

Group MedicareBlue Rx - Iowa (use with Iowa Choice or National Choice) 
Group MedicareBlue Rx (use with Group Program F or Group Program N)
Group MedicareBlue Rx Electronic Funds Transfer (EFT) form

Dental Insurance Application

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

updated 12/04/2018