Dental & Vision Insurance Forms for Retired Members

Forms Policy

1. Digital signatures are not accepted by NDPERS.
2. Completed forms must be submitted to NDPERS by fax, by mail, or as a scanned PDF.
3. NDPERS does not accept picture files such as .jpeg, .jpg, .tif, or .png.

Select a form to download:

For Dental & Vision Plans

• Retiree Vision/Dental Insurance Enrollment/Change (SFN 53504)
• Authorization for Automatic Premium Deduction (SFN 50134)
• Verification of Alternate Retirement Plan (SFN 53863)
• Application for Dependent Disability (SFN 58856)
• Grandchild Eligibility Verification (SFN 60983)
• Physician's Form for Dependent Disability [(SFN 58798)

For Vision Plan only

• Provider Nomination Form
• Vision Reimbursement Claim Form
• How to File a Claim Guide

Other general forms

• Authorization to Release Confidential Information (SFN 61324)
• Notice of Change for Name & Address (SFN 10766)