NCPERS RESOURCE LIBRARY

ENROLLMENT & BENEFICIARY FORMS

Employee Enrollment Form (NCPERS $16 Plan)

Please submit your complete enrollment form to your employer. Your employer will begin payroll deductions
and forward your enrollment information to Member Benefits.

Request For Certificate Form

Complete this form to request a copy of your certificate of coverage.

Beneficiary Designation/Change Form

Use this form to designate or make changes to the beneficiary(ies) of your Group Insurance death proceeds.

Change/Update Contact Information

Update your contact information such as address, phone number and email address by completing this form.

DEATH CLAIM FORMS

Death Claim Form (All States except MN)

Use this form and instructions to file a death claim for the NCPERS Group Life Insurance.

Death Claim Form (Only Minnesota)

Use this form and instructions to file a death claim for the NCPERS Group Life Insurance.

PAYMENT FORMS

Monthly Auto Pay Form

Monthly auto-pay is provided as a convenience for you to pay premiums via automatic bank draft (ACH) on a monthly basis.