General Enrollment Application
For Instuction on how to complete this form, click here.

DUE within 31 days of your retirement, or last day of insurance coverage through your employer, whichever is later.

 

First Premium Payment Worksheet

DUE within 31 days of your retirement, or last day of insurance coverage through your employer, whichever is later.

 

Work History Form

DUE within 31 days of your retirement, or last day of insurance coverage through your employer, whichever is later.

Extension of Benefits Questionnaire
*This is a Microsoft Word Document.

Change Request Form
This is the form to cancel your coverage, or change your personal information. You can use this form to change levels, or amount of coverage as well as change the method of your premium payment. (The instructions for filling out this form are in the pdf.)

Change Beneficiary Form
This form is for changing your feneficiary(ies) for retiree or surviving dependent life policy(ies).

Eligible Spouse's Beneficiary Form
If your spouse is also an NMRHCA-eligible retiree and they wish to name a beneficiary for life insurance then use this form.

Switch Enrollment Form
Use this form to select new plans or switch your current plans during our annual Switch Enrollment Period. Insturctions for completing Switch Enrollment