Retiree Benefits Election Form
  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
*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.  
   
  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.  
 
 
  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.  
 
 
  *