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Name of Retiree*:  
Address*:  
City*:   State*:   Zip*:    
SSN (Last 4 Digits)*:    
Medical Program*:  
Effective Date*: Click Here For Date  
Cancel Coverage On*: Click Here For Cancel Coverage Date
Relationship*:  
SSN*:    
I hereby cancel medical coverage under the retiree health benefit. I understand that the person listed above will not be eligible to re-enroll at a later date,as I have permanently waived eligibility for coverage under the retiree health benefit program.
Change form can be submitted via the website, although the change will not be effective until the retiree has met with a Benefits Specialist. Visit the Pension Fund Benefits office to make this change.