Personal Information		* Required fields
	*Last Name M.I. *First Name *Date of Birth (mm/dd/yyyy)
	*SSN (ex. 111-11-1111) *Phone Number (ex. 123-456-7890) *Email Address (ex. user@domain.com)
	*Mailing Address *City *State Other Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *Zip (ex. 99999)
	*Alternate Contact Name *Alternate Phone Number(ex.111-111-1111) *Alternate Contact Relationship
	I give my permission to allow employees of the Katy ISD Risk Management Department to discuss my Life and Dental accounts with my Alternate Contact named above.
	Yes No
	Please read below to understand what benefits are available as a Retiree.

	Basic Life Insurance Election Information
	*I understand that as a retiree of the Katy Independent School District, I am eligible to retain the Basic Life coverage in effect at the time of my retirement, (not including Accidental Death and Dismemberment (AD&D)). The premiums will be billed to me directly by the Katy ISD on an annual invoice. Failure to submit payment within 31 days of the due date may result in termination of coverage.
	No, I do not wish to continue my enrollment in the Katy ISD Basic Life Coverage. Yes, As a retiree of the Katy ISD, I wish to continue my enrollment in the Katy ISD Basic Life coverage. Future changes are not allowed.

	Dental Insurance Election Information
	*I understand that as a retiree of the Katy Independent School District, I am eligible to retain the Dental coverage in effect at the time of my retirement. The premiums will be billed to me directly by Katy ISD. Failure to submit payment within 31 days of the due date may result in termination of coverage.  NOTE: If you elect to retain your Dental coverage as a KATY ISD Retiree, you should NOT enroll in COBRA coverage for Dental.
	No, I do not wish to continue my enrollment in the Katy ISD Dental Coverage. Yes, As a retiree of the Katy ISD, I wish to continue my enrollment in the Katy ISD Dental coverage. Future changes are not allowed.

*By submitting this election form, I certify that I have reviewed this information and understand that I must submit this retiree election form within sixty (60) days of retirement.