FORMS and Brochures
Forms for Newly Eligible Employees
The documents listed below must be provided within 10 business days of an employee’s initial eligibility for ORP coverage.
- ORP Enrollment Guide and provider inserts (Hard copies available by request)
- Form SSA-1945 (.PDF)
- ORP Enrollment/Change Form (.PDF)
- Insurance Enrollment/Beneficiary Change Form (.PDF)
- SERS Application to Withdraw Accumulated Pension Deductions (Refund/Rollover Request Form) (.PDF)
Forms are provided as PDF documents for completion and printing. All forms must be physically signed and returned promptly to the Plan Administrator at the Board of Higher Education. Copies should be retained for on-site personnel folders.
In addition, the Notice of ORP Eligibility (.DOC) form letter may be used to establish and monitor enrollment deadlines.
Form for Changes in Participant Status
Campus Administrators must report changes in ORP Participants' status to the Plan Administrator as soon as possible using the following form:
Click here to access participant information relating to total Years of Creditable Service and Retiree Income on the DHE database.
ORP Insurance Forms
Please contact Lynne Goldberg at (617) 994-6960 or firstname.lastname@example.org if you need claim forms for either Group Life Insurance or Long-Term Disability Insurance.