Enrollment Forms

Employee Enrollment Form

NCPERS $16 Plan - New Enrollment

Beneficiary Change Form

Designate or Change Beneficiary(ies)

Claim Forms

Death Claim Form

All States except Minnesota

MN Death Claim Form

Minnesota Only

Plan Brochures & Videos

$16 Plan Overview Video

NCPERS Group Life Insurance - $16 Plan

$17 Plan Overview Video

NCPERS Group Life Insurance - $17 Plan

Online Forms

Contact Information Form

Change/Update Contact Information

Certificate Request Form

Request New/Updated Certificate of Coverage

Monthly Auto Pay Form

Sign-Up or Update Monthly Auto Payment

Since the plan’s inception more than 40 years ago, Prudential has paid over $105 million to NCPERS members and their beneficiaries. It currently serves the needs of over 85,000 public employee retirement system members nationwide.

Public Employee Financial Protection Plan (formerly Group Decreasing Term Life Insurance, Dependent Group Decreasing Term Life Insurance, and Accidental Death and Dismemberment Insurance) is issued by The Prudential Insurance Company of America, a Prudential Financial company, Newark, New Jersey. A Booklet-Certificate, with complete information, including limitations and exclusions, will be provided. If there is a discrepancy between this document and the Booklet-Certificate issued by Prudential, the terms of theBooklet-Certificate will govern. Contract Series: 83500.

Option To Accelerate Payment of Death Benefits is a feature that is made available to group life insurance participants. It is not a health, nursing home, or long-term care insurance benefit and is not designed to eliminate the need for those types of insurance coverage. The death benefit is reduced by the amount of the accelerated death benefit paid. There is no administrative fee to accelerate benefits. Receipt of accelerated death benefits may affect eligibility for public assistance and may be taxable. The federal income tax treatment of payments made under this rider depends upon whether the insured is the recipient of the benefits and is considered terminally ill. You may wish to seek professional tax advice before exercising this option.

This AD&D policy provides ACCIDENT insurance only. It does NOT provide basic hospital, basic medical, or major medical insurance as defined by the New York Department of Financial Services.


The plan is administered by Member Benefits. Gallagher Benefit Services, Inc. and Member Benefits are not affiliates of Prudential.

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Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide.